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OPERATIVE  SURGERY 
Bl  NNI  E 


MANUAL  OF 


OPERATIVE  SURGERY 


BY 


JOHN  FAIRBAIRN  BINNIE,  A.  M.,  C.  M.  (Aberdeen) 

SURGEON  TO  THE   GENERAL    HOSPITAL,   KANSAS   CITY,   MO.;    FELLOW   OF  THE  AMERICAN 
SURGICAL  association;   MEMBRE  DE  LA  SOCIETE  INTERNATIONALE  DE  CHIRURGIE. 


FIFTH  EDITION,  REVISED  AND  ENLARGED 


WITH  1365  ILLUSTRATIONS 
A  NUMBER  OF  WHICH  ARE  PRINTED  IN  COLORS 


PHILADELPHIA 
BLAKISTON'S  SON  &  CO. 

1012  WALNUT  STREET 
1912 


Copyright,  1911,  by  P.  Blakiston's  Son  &  Co. 


T  ■    T; 


Printed  by 

The  Maple  Press 

York,  Pa. 


PREFACE  TO  THE  FIFTH  EDITION. 

November,  1911. 

K.  M.  Blakiston,  Esq., 
Philadelphia, 

Dear  Sir: 

You  suggested  to  me  that  our  Manual  of  Operative  Surgery  should  be  issued 
in  one  volume  instead  of  in  two.  I  thoroughly  agreed  with  you  in  your  sugges- 
tion and  am  glad  to  say  that  several  friends,  whose  judgment  I  trust,  concurred 
in  the  wisdom  of  so  doing.  The  original  work  was  issued  in  one  rather  small 
volume  in  which,  for  various  reasons,  no  account  was  given  of  operations  on  the 
bones  and  joints,  etc.  Later  it  was  determined  to  include  these  subjects.  It 
would  have  been  manifesdy  unfair  to  have  compelled  those  who  possessed  the 
original  volume  and  who  desired  the  complete  work  to  repurchase  what  they 
already  possessed— hence,  the  new  material  was  published  in  a  separate  volume. 
This  debt  to  the  above  class  of  purchasers  having  been  fulfilled,  I  think  we  are 
fully  justified  in  returning  to  the  original  idea  of  one  volume  which  is  more 
practical  so  long  as  the  book  is  not  too  large  and  clumsy. 

The  present  issue  represents  the  fifth  edition  of  Vol.  I.  and  the  second  of 
Vol.  II.  I  have  endeavored  to  bring  the  contents  up  to  date  and  hope  that  the 
book  in  its  new  dress  may  find  favor  with  the  medical  public. 

As  on  previous  occasions  I  have  to  thank  Dr.  John  G.  Hayden  and 
Mrs.  C.  M.  Bossier  for  most  valuable  assistance.  Personally,  I  desire  to 
thank  you  for  the  great  interest  taken  in  the  manual  both  by  yourself  and  by 

your  very  efficient  staff. 

Yours  sincerely, 

J.   F.    BiNNIE. 


LIST  OF  CONTENTS. 


PART  I. 


Head  and  Neck. 

Chapter  Page 

I.  Scalp i 

II.  The  Skull  and  the  Brain 6 

III.  Frontal  Sinus 53 

IV.  Tic  Douloureux 56 

V.  Plastic  Operations  on  the  External  Ear 73 

VI.  Empyema  oe  the  Antrum  of  Highmore 80 

VII.  Osteoplastic  Exposure  of  the  Orbit      82 

VIII.  Excision  of  Upper  Jaw 83 

IX.  Lower  Jaw.     Resection 90 

X.  Odontomata 96 

XL  Excision  of  the  Cheek 97 

XII.  Lower  Lip 103 

XIII.  Hare-lip 117 

XIV.  Cleft  Palate      125 

XV.  Tongue 140 

XVI.  Parotid  Gland 152 

XVII.  Excision  of  Intranasal  Malignant  Tumors 157 

XVIII.  Torticollis,  Wry-neck,  Caput  Obstipum 174 

XIX.  Excision  of  Cervical  Tumors 178 

XX.  Excision  of  the  Cervical  Sympathetic 185 

XXI.  Retropharyngeal  Abscess  and  Tumors 189 

XXII.  (Esophagus      192 

XXIII.  Pharyngotomy,  Laryngotomy,  Partial  Laryngectomy, 

AND  Laryngectomy 196 

XXIV.  Tracheotomy 206 

XXV.  Foreign  Bodies  in  Trachea  or  Bronchus 210 

XXVI.  Goitre;  Bronchocele,  Struma 215 

XX\TI.  Thymus  Gland 233 

PART  II. 

The  Thorax. 

XXVIII.  Operations  on  the  Breast 235 

XXIX.  Operations  on  the  Chest 246 

vii 


Vlll  CONTENTS. 

PART  III. 

The  Abdomen. 

Chapter  Page 

XXX.  Laparotomy;  Celiotomy;  Abdominal  Section     ....  277 

XXXI.  The  Stomach 289 

XXXII.  Operations  on  the  Intestines 331 

XXXIII.  The  Vermiform  Appendix  and  Peritoneum 371 

XXXIV.  The  Rectum 386 

XXXV.   HEMORRHOIDS 416 

XXXVI.  Ascites 422 

XXXVII.  The  Pancreas 428 

XXXVIII.  The  Spleen 440 

XXXIX.  The  Suprarenal  Bodies .  445 

XL.  Operations  Upon  the  Liver 446 

XLI.  Operations  on  the  Biliary  Passages 454 

XLII.  Hernia 482 

XLIII.  Retro-peritoneal  and  Diaphragmatic  Hernia  ....  507 

PART  IV. 

The  Genito-Urinary  System. 

XLIV.  Operations  Upon  the  Kidney 513 

XLV.  Operations  on  the  Ureter  . 545 

XLVI.  Operations  on  the  Bladder 557 

XLVII.  Perineal  Section 582 

XLVIII.  Urethral  Stricture 590 

XLIX.  Epispadias 598 

L.  Hypospadla-s 601 

LI.  Amputation  of  Penis 608 

LII.  Circumcision 613 

LIII.  Operations  on  the  Testicles 615 

LIV.  Hydrocele 625 

LV.  Varicocele     627 

PART  V. 

The  Spine. 

LVI.  Operations  on  the  Spine 629 

PART  VI. 

Unclassified  Topics. 

LVII.  Acute  Abscess 651 

LVIII.  Methods  of  Drainage 654 


CONTENTS.  IX 

Chapter  Page 

LIX.  Nerves 657 

LX.  Principles  of  Plastic  Surgery 681 

LXI.  Ligatures  and  Sutures     687 

LXII.  Arteriorrhaphy 692 

LXIII.  Aneurysm 704 

LXIV.  Ligation  of  Arteries  in  Continuity 716 

LXV.  Operations  on  Veins 737 

LXVI.  Operative  Treatment  of  Simple  Fractures,  Exclusive 
of  Those   Involving  Articulations  and   of   some 

Special  Fractures      754 

LXVTI.  Compound  or  Open  Fractures 763 

LXVIIL  Ununited  Fracture,  Pseudarthrosis 766 

LXrX.  Fractures,  Malunion 783 

LXX.  Special  Fractures 789 

LXXL  Osteomyelitis 810 

LXXII.  Tumors  of  Bone 827 

LXXIII.  Chondrectomy 831 

LXXIV.  Osteotomy 832 

LXXV.  Bow-leg,  Genu  Varum 843 

LXXVT.  Operations  on  the  Pel\tc  Bones 846 

LXXVIL  Sacro-iliac  Disease 850 

LXXVIIL  Hn» 853 

LXXIX.  Hep,  Arthritis  Deformans 864 

LXXX.  Osteotomy  Hip     865 

LXXXI.  Old  Dislocations  of  the  Hip 879 

LXXXn.  Congenital  Luxation  of  the  Hip  883 

LXXXni.  Knee-joint      900 

LXXXIV.  Patella,  Tuberculosis 921 

LXXXV^  Osteotomy  for  Bony  Anchylosis  of  the  Knee    .    .  924 

LXXXVI.  Dislocation  of  the  Patella 933 

LXXXVn.  Ankle 936 

LXXXVHL  Dislocation  of  the  Astragalus 943 

LXXXK.  Subastragaloid  Dislocation 944 

XC.  Os  Calcis 945 

XCL  Bunion 947 

XCn.  Operations  on  the  Scapula  and  Clavicle 952 

XCHL  Shoulder 962 

XCrV.    CLAVICUL0-HUMER.4L   NEARTHROSIS 982 

XCV.  Subacromial  or  Subdeltoid  Bursitis 985 

XCVI.  Elbow 986 

XCVII.  Irreducible  Dislocation  of  the  Elbow      993 

XCVIII.  Anchylosis,  Elbow 996 

XCIX.  Wrist ' 1002 


X  CONTENTS. 

Chapter  Pace 

C.  Wrist  Anchylosis 1006 

CI.  Metacarpophalangeal  dislocations 1008 

CII.  Syndactylism     1009 

cm.  Trigger;  Snapping  OR  Spring  Finger loio 

CIV.  Operations  for  Infective  Lesions  of  the  Hand     .    .  1012 

CV.  Wounds  of  Joints 1022 

CVI.  Indications,  Joints 1023 

CVII.  Amputation  or  Disarticulation 1026 

CVIII.  Flat-foot 1069 

CIX.  Tendon  Sheaths  and  Tenorrhaphy 1072 

ex.  Tenotomy iioo 

CXI.  Dupuytren's  Contracture        1116 

Index 11 19 


MANUAL  OF  OPERATIVE  SURGERY, 


PART  I.-HEAD  AND  NECK. 


CHAPTER  I. 
SCALP. 


REMOVAL  OF  SEBACEOUS  CYSTS  (WENS). 

Method  A. — Make  an  incision  through  the  skin  into  the  cyst.  The  incision 
must  be  nearly  as  long  as  the  diameter  of  the  tumor.  Do  not  squeeze  out  the 
contents  of  the  cyst.  Seize  the  divided  cyst  wall  with  a  strong  forceps  (hemo- 
stat).  With  a  twisting  motion  it  is  easy  to  pull  out  the  whole  sac.  Apply 
pressure  to  the  wound  for  a  few  seconds.  Close  the  wound  with  one  or  more 
sutures.     Dress. 

Method  B. — Make  a  free  incision  through  the  skin  (which  is  thin  over  the 
tumor)  down  to,  but  not  into  the  cyst.  Dissect  out  the  cyst  unbroken.  Close 
the  wound.     Dress. 

Method  C. — If  the  cyst  is  infected  and  suppurating,  treat  it  either  as  an 
abscess  or  better  excise  it  plus  the  infected  portion  of  skin. 

In  cases  where  the  cyst  is  not  adherent  and  not  inflamed,  method  A  is  ex- 
tremely easy  and  gives  perfect  results ;  opening  the  cyst  permits  removal  through 
a  comparatively  small  cut,  and  the  author  has  never  seen  harm  result  from  escape 
of  cyst  contents. 

ANGIOMA  OF  SCALP. 

When  simple  nevi  of  the  scalp  require  removal  by  operation,  the  incision 
must  be  made  sufficiently  far  from  the  disease  so  that  hemostasis  may  be  easily 
effected;  the  wound,  if  extensive,  may  tax  the  resources  of  plastic  surgery. 
Rapidly  growing  angiomata,  those  which  penetrate  the  subcutaneous  tissues  or 
are  large  and  tumor-like  and  those  which  bleed  or  threaten  severe  hemorrhage, 
all  call  for  operation. 

Angiomata  over  the  fontanelles  often  communicate  with  the  longitudinal 
sinus,  hence  in  these,  radical  operation  should,  if  possible,  give  way  to  less 
vigorous  measures  such  as  ignipuncture.  The  same  is  true  in  the  case  of 
cavernous  angiomata,  which  evidently  penetrate  the  skull. 


2  SCALP. 

(A)  Strangulation. — Pass  a  stout  pin  or  needle  under  the  middle  of  the 
nevus  from  side  to  side.  Pass  a  stout  thread  around  the  base  of  the  nevus, 
under  the  pin  (which  keeps  the  thread  from  slipping).  Tie  the  thread  very 
tightly.  Instead  of  one,  two  pins  may  be  introduced  at  right  angles  to  each 
other.  In  time  the  strangulated  tissues  die,  slough  oflf  and  leave  an  ulcer  In 
the  twentieth  century  this  treatment  savors  of  barbarism. 

(B)  Subcutaneous  Ligation. — Many  methods  of  subcutaneous  ligation 
have  been  used ;  most  of  them  are  exceedingly  simple. 

I.  At  the  points  A,  B,C,  D  (Fig.  i)  puncture  the  scalp  with  a  knife.  These 
points  must  be  well  away  from  the  disease.  With  a  needle  introduce  a  stout 
chromicized  catgut  or  a  silk  suture  through  A  and  bring  it  out  at  B,  reintroduce 
at  B  and  bring  out  at  C;  in  the  same  manner  carry  the 
suture  from  C  to  D  and  from  D  to  A.  Both  ends  of  the 
suture  now  emerge  at  A .  Tie  the  suture  tightly  and  let 
its  knot  retract  under  the  skin  through  the  puncture  at  A . 
D  .v'  \      Apply  dressings. 

f^        II.  Krogius  ("Centralblatt  fiir  Chir.,"  Sept.  30,  1905) 
''^    found  that  compression   and  ligation  even,  of  the  ailerent 
■^•-::-..  .-:<-'  vessels  was  inefficient  in  cases  of  large  racemose  (cirsoid) 

^^  angiomata  of  the  scalp;  that  ignipuncture,  injections  and 

Fig.  I.  excision  were  dangerous.     He  therefore  devised  the  follow- 

ing method  of  subcutaneous  ligation:  Arm  a  full  curved 
needle  with  catgut.  Pass  the  needle  from  A  to  B  (Fig.  2),  hugging  the  bone.. 
Remove  the  full  curved  and  substitute  a  less  curved  needle.  With  this  pass 
the  suture  from  B  to  A  immediately  under  the  skin  (Fig.  3).  Both  ends  of 
the  suture  now  emerge  at  A.     Tie  the  suture  tightly. 

Repeat  the  process  all  round  the  nevus  until  practically  every  vessel  entering 
or  leaving  the  tumor  is  controlled.  Each  suture  or  ligature  should  to  some 
extent  overlap  into  the  territory  controlled  by  the  next  one. 

(C)  Bryant's  Operation. — Suitable  in  cases  of  cirsoid  growth.  Make  an 
incision  outside  and  nearly  round  the  growth,  down  to  the  periosteum.  Leave 
undisturbed  that  portion  of  growth  containing  the  largest  vessels.  Raise  the 
flap  and  attend  to  hemostasis.  Apply  dressings  under  as  well  as  over  the  flap. 
When  the  wound  is  covered  with  granulations,  replace  and  suture  the  flap. 
If  after  elevation  of  the  flap  for  a  few  days  pulsations  continue  in  the  flap  (the 
tumor  is  in  the  flap),  ligate  at  a  distance  the  main  vessel  entering  it.  This 
method  has  given  J.  D.  Bryant  much  satisfaction. 

Clairmont  reports  from  v.  F.iselsberg's  clinic  (''Archir.  fur  klin.  chir.," 
Ixxxv,  549)  an  operation  which  combined  the  principles  of  Bryant's  operation 
and  excision.  Following  Krause,  the  operation  was  completed  in  two  sittings 
Figs.  4  and  5  show  the  extent  of  the  disease.  A  skiagram  showed  that  the 
middjie  meningeal  arteries  were  much  enlarged.  The  occipital  limits  of  the 
tumor  were  clearly  defined;  elsewhere  it  was  not  well  delimited.  The  use  of 
temporary  hemostasis  by  an  elastic  band  was  impossible.     Preliminary  ligation 


NEVUS.  3 

would  have  called  for  the  tying  of  both  occipital  arteries,  the  frontal  artery 
(the  size  of  the  Httle  finger),  and  both  external  carotids  near  their  origin,  which 
might  cause  danger  of  embolism.  Communicating  vessels  between  the  scalp 
and  the  inside  of  the  skull  were  so  numerous  as  to  make  the  gain  from  prelimi- 
nary ligations  very  doubtful.  The  operation  performed  may  be  taken  as  a  guide 
for  the  treatment  of  extremely  extensive  cirsoid  aneurysm  of  the  scalp. 
Place  the  patient  almost  in  a  sitting  posture.     Anesthetize. 


Fig.  2. 

Step  I. — Make  an  incision  through  the  skin  and  epicranial  aponeurosis, 
skirting  the  growth  anteriorly  and  laterally.  Make  the  cut  inch  by  inch, 
using  compression  on  each  side  of  the  cut  against  the  bone  until  the  vessels  are 
secured  by  forceps  and  ligatures.  Isolate  and  doubly  ligate  the  main  vessels 
before  dividing  them.  This  incision  outlines  a  horseshoe-shaped  flap  having 
its  base  at  the  occiput. 

Step  2. — Reflect  the  flap  from  the  cranium.  This  step  requires  the  use  of 
many  hemostats  and  ligatures  because  of  the  free  anastomosis  with  the  deep 
vessels. 


je/rwi-^-w-fj 


Fig.    3. 


Step  3. — As  in  Byrant's  operation,  place  gauze  between  the  flap  and  the  bone. 
Replace  the  flap  over  the  gauze.     Apply  dressings  and  bandage. 

Step  4. — After  three  or  four  days  remove  the  dressings  and  excise  the  tumor 
from  the  under  surface  of  the  flap.  Thrombosis  of  the  vessels  in  the  tumor,  and 
loosening  of  the  surrounding  connective  tissue  due  to  edema,  make  the  excision 
of  the  growth  easier  than  it  would  have  been  at  the  first  sitting. 

Step  5. — Replace  the  flap.     Suture.     Dress  the  wound. 

(D)  Excision. — It  is  very  easy  to  excise  small  nevi  and  to  close  the  wound 
with   sutures.     When  large   nevi   are  being   excised  hemorrhage  during  the 


4  SCALP. 

excision  may  be  avoided  by  tying  an  elastic  constrictor  tightly  round  the  head 
as  in  trephining  or  by  having  a  rubber-covered  ring  (ring  pessary)  pressed  firmly 
against  the  scalp  surrounding  the  nevus.  The  operation  consists  in  excising 
the  disease  by  cutting  through  healthy  tissue,  in  securing  hemostasis  and  in 
closing  the  wound  either  directly  or  by  some  plastic  procedure. 

The  freezing  treatment  of  nevi  threatens  to  displace  all  other  methods. 

Liquid  Air. — First  get  the  liquid  air.  Make  a  very  firm  pad  of  cotton  on  the 
end  of  a  stick.     Dip  the  pad  in  liquid  air.     Shake  off  any  loose  drop  of  the  liquid. 


Fig.  4. — (Clairmont.) 


Fig.  5. — Clairmont.) 


Press  the  charged  pad  with  moderate  firmness  on  to  the  nevus  for  a  few  seconds. 
Repeat  the  process  on  every  part  of  the  lesion.  The  treatment  is  usually  painless. 
Apply  no  dressings.  If  any  raw  surfaces  are  present  on  the  lesion  they  must  be 
covered  with  thin  gauze  before  being  treated,  otherwise  the  applicator  would 
freeze  to  them  (Whitehouse) ;  all  scabs  must  be  removed  prior  to  treatment. 
The  applications  may  require  to  be  repeated  two  to  three  times  at  intervals 
of  about  one  week. 


MALIGNANT  TUMORS  OF  THE  SCALP. 

The  principles  of  operation  are  the  same  as  obtain  in  other  situations,  viz., 
free  excision  and,  especially  in  the  case  of  epithelioma,  removal  of  the  lymphatics 
which  drain  the  site  of  disease,  when  this  is  possible.  The  main  features  of  the 
anatomy  of  the  lymphatics  of  the  scalp  are  as  follows: 

{A)  The  lymphatics  of  the  frontal,  and  the  anterior  part  of  the  parieto- 
occipital regions,  drain  into  the  parotid  lymph  glands.  These  glands  for  the 
most  part  lie  in  the  parotid,  and  their  removal  means  removal  of  the  parotid. 
A  cancer  of  the  scalp,  with  secondary  nodes  in  the  parotid,  is  practically 
inoperable. 


TUMORS    OF   SCALP.  5 

(B)  The  lymphatics  of  the  posterior  part  of  the  parieto-occipital  region  drain 
into  the  mastoid  group  of  glands  lying  on  the  mastoid  portion  of  the  stemo- 
mastoid  muscle.     These  are  easily  extirpated. 

(C)  The  occipital  region  is  drained  by  two  routes.  From  the  outer  part, 
the  lymphatics  join  to  form  a  single  trunk  which  runs  downwards  to  a  point 
under  the  sterno-mastoid  muscle,  where  it  enters  one  of  the  external  glands  of 
the  sterno-mastoid  group.  From  the  inner  part  of  the  region,  the  lymphatics  go 
to  the  occipital  glands. 

From  the  foregoing  it  is  clear  that  only  in  case  of  frontal  and  anterior  tem- 
poro-parietal  cancer,  are  the  lymphatic  nodes  "next  in  order"  really  inaccessible. 
When  a  cancer  of  the  scalp  is  freely  movable — excise  it  thoroughly  but  leave  the 
skull  intact;  the  wound  may  be  closed  by  sutures,  by  flaps  of  skin,  or  by  skin 
grafts.  When  the  cancer  is  adherent  to  the  bone,  make  an  incision  down  to 
the  bone  all  round  the  disease,  but  in  healthy  tissue.  With  the  chisel  introduced 
through  the  incision,  cut  away  all  the  external  table  of  the  skull  corresponding  to 
the  diseased  area.  If  for  any  reason  it  is  thought  that  the  disease  has  penetrated 
the  diploe  it  becomes  necessary  to  remove  the  whole  thickness  of  the  skull. 
The  cranial  defect  should  be  closed  at  once  by  the  Muller-Konig  method. 
V.  Bergmann  writes,  "when  the  disease  affects  the  frontal  or  occipital  regions 
we  do  not  hesitate  to  penetrate  the  dura  and  remove  portions  of  the  cerebral 
cortex." 


CHAPTER  II. 
THE  SKULL  AND  THE  BRAIN. 

EXPOSURE  OF  THE  SKULL. 

Many  means  of  exposing  the  skull  may  be  employed,  all  of  which  must  be 
preceded  by  the  shaving  of  a  large  part,  or,  still  better,  of  all  the  scalp.  In  cases 
of  open  fracture,  one  may  expose  the  bone  sufl&ciently  by  enlarging  the  wound 
already  existing.  When  the  operation  is  for  the  removal  of  a  foreign  body 
lodged  In  the  bone,  a  linear  incision  may  be  employed.  The  same  incision  may 
sufl&ce  to  lay  bare  enough  bone  for  the  application  of  Doyen's  perforator  or  a 
very  small  trephine.  When  a  moderate  sized  trephine  is  to  be  used  or  one  desires 
to  explore  the  surface  of  the  skull,  the  best  incision  is  one  curved  in  the  form  of  a 
U  or  horseshoe.  Unless  specially  contraindicated  the  open  end  of  the  U  should 
face  downwards  in  the  direction  of  the  blood-supply  of  the  scalp.  The  knife 
penetrates  to  the  bone  at  the  first  cut  and  the  flap  is  rapidly  and  readily  reflected 
downwards.  Hemostasis  must  be  attended  to  at  once.  Before  incising  the 
scalp  some  surgeons  tie  an  elastic  constrictor  round  the  head  immediately  above 
the  ears  so  that  hemorrhage  may  be  controlled.  Lanphear  attains  the  same  end 
by  surrounding  the  site  of  operation  with  a  continuous  chain  suture,  each  stitch 
of  which  includes  the  whole  thickness  of  the  scalp.  When  operating  in  a  region 
supplied  by  the  temporal  artery,  it  is  convenient  to  have  an  assistant  exert 
pressure  thereon. 

When  the  U-shaped  incision  is  preliminary  to  the  reflection  of  a  flap  com- 
posed of  skin,  periosteum,  and  bone,  hemostasis  must  be  effected  as  soon  as  the 
cut  is  made,  and  the  flap  outlined  must  not  be  separated  from  the  underlying 
bone. 

METHODS  OF  OPENING  THE  SKULL. 

(A)  The  Trephine. — There  are  two  species  of  trephine,  but  of  these  there 
are  many  modifications: 

I.  The  ordinary  trephine  is,  in  principle,  merely  a  hollow  steel  cylinder 
whose  lower  end  is  provided  with  a  saw-edge.  To  keep  the  saw-edge  in  position 
on  the  skull,  a  pin  projects  through  the  centre  of  the  cylinder.  The  pin  is 
withdrawn  as  soon  as  the  trephine  has  cut  a  groove  in  the  bone  sufficiently  deep 
to  prevent  it  from  slipping.  Power  is  applied  to  the  instrument  through  a 
T-shaped  handle  or  a  " brace"  similar  to  those  used  by  carpenters.  To  prevent 
any  sudden  onward  movement  of  the  instrument  into  the  brain  after  the  inner 

6 


TREPHINES. 


table  of  the  skull  is  penetrated,  movable  guards  may  be  fixed  to  the  outside  of  the 

trephine.     (See  Fig.  6.) 

2.  The  Gait  Trephine. — The  principle  of  this  trephine  is  identical  with  the 

preceding  except  that  the  cutting  part  of  the  instru- 
ment is  shaped  like  a  truncated  cone  (Fig.  7).      The 

conical  shape  prevents  any  sudden  onward  movement 

when  the  inner  table  of  the  skull  is  penetrated.     The 

Gait  trephine  is  most  commonly  used  in  America.     The 

only  disadvantage  of  this  instrument  is  that  on  account 

of  its  shape  it  necessarily  makes  the  button  of  bone 

removed  much  smaller  than  the  hole  left  in  the  skull,  a 

matter  of  some  importance  if  one  intends  reimplanting 

the  bone  removed. 

Trephming. — Place  the  patient  with  his  head  resting 

on  a  sand-bag  and  held  steady  by  the  hands  of  an 

assistant  (Fig.   8).     Expose  the  skull  as  already  de- 
scribed.    Make  the  centre  pin  of  the  trephine  protrude 

about  one-sixteenth  of  an  inch  beyond  the  cutting-edge 

and  bore  it  into  the  skull  at  the  selected  site.     By  steady 

movements  of  the  wrist,  twist  the  trephine  from  left  to 

right  and  right  to  left  until  it  has  cut  a  groove  in  the 

skull.     Withdraw  the  centre  pin  and  proceed  with  the 

trephining.     As  soon  as  the  outer  table  of  the  skull  is 

penetrated  there  will  be  less  resistance  to  the  operation 

and  more  escape  of  blood.  As  soon  as  hard  bone  is  again  met, 
proceed  with  increased  caution.  The  inner  table  is  often  very  thin. 
After  every  few  movements  of  the  instrument  probe  the  groove  in  the 
skull  with  the  blunt  end  of  a  straight  needle.  If  probing  shows 
greater  penetration  at  one  part  of  the  groove  than  another,  lessen 
the  pressure  of  the  trephine  at  that  point.  The  inner  table  is  usually 
found  divided  at  one  place  before  another;  when  this  is  the  case, 
by  slightly  tilting  the  trephine  the  place  where  penetration  has 
already  taken  place  is  avoided  while  the  rest  of  the  skull  is  being 
divided.  As  soon  as  the  bone  is  divided  the  resulting  button  is 
easily  removed  and  the  dura  mater  exposed.  Along  the  edges  of  the 
osseous  hole  there  will  always  be  found  projecting  spicvdes;  these 
must  be  cut  away  with  rongeur  forceps.  If  bleeding  from  the  cut 
bone  is  severe,  it  may  be  stopped  by  sponge  pressure,  or,  if  necessary, 
by  slightly  crushing  the  bone  between  the  jaws  of  a  rongeur 
forceps.  In  the  author's  practice  this  last  procedure  has  almost 
never  failed  to  give  satisfaction  and  to  have   no   subsequent  ill 

results.     Horsley's  wax  (beeswax  7,  almond  oil  i,  salicylic  acid  i)  applied  to 

the  bleeding  bone  is  an  efficient  hemostatic  agent.     Leonard  Freeman  finds 

sterilized  chewing  gum  most  convenient  for  this  purpose,  but  outside  of  the 


Fig.  6. — Trephine  and 
"Brace." 
B.  Trephine:  i,  Center 
pin;  2,  movable  guard;  3, 
stem  to  fit  into  brace.  C. 
Extra  stem  by  which  burs 
or  drills  may  be  attached 
to  brace. — (Monod  and 
Vanverts.) 


Fig.  7. 
{Tiemann.) 


8 


THE   SKULL  AND   THE   BRAIN. 


United  States  this  material  will  never  be  within  reach.  Should  there  be  any 
intention  to  reimpl^nt  the  button  of  bone  removed,  it  must,  at  once,  be  placed  in 
sterile  water  and  kept  at  a  temperature  of  about  ioo°  F. 


Fig.  8. 


Fig.  9.^Use  of  Keen's  Forceps. 
Appearance  of  trap-door  opening  in  skull. 


The  most  convenient  size  of  trephine  for  ordinary  purposes  is  one  three- 
fourths  of  an  inch  in  diameter.  Smaller  instruments  are  often  useful.  Tre- 
phines having  a  diameter  much  greater  than  one  inch  are  useless  owing  to  the 
curvature  of  the  cranial  vault. 


TREPHINING.  9 

Should  it  be  desired  to  enlarge  the  trephine  opening,  this  iseasUy  accom- 
plished by  biting  away  the  surrounding  bone  with  rongeur  forceps.  Keen's 
forceps  are  excellent  for  this  purpose  (Figs.  9  and  10). 

Occasionally  the  dura  is  accidentally  injured  by  the  trephine  and  bleeding 
occurs.  When  this  is  the  case,  enlarge  the  hole  in  the  skull  so  that  free  access 
is  obtained  to  the  dural  wound,  surround  any  bleeding  vessel  by  a  fine  suture, 
and  close  the  rent  in  the  dura. 

(B)  Chisel  and  Mallet. — Especially  on  the  continent  of  Europe,  the  skull 
is  frequently  opened  by  means  of  a  chisel.     In  America  and  England  the  method 


DeVilbiss'  Forceps. 


Keen's  Forceps. 
Fig.  id. 


is  not  a  general  favorite.  The  writer  has  more  than  once  observed  severe  shock 
result  from  it.  Either  the  ordinary  chisel  or  a  gouge  with  a  V-shaped  cutting- 
edge  may  be  employed.  Support  the  patient's  head  on  a  sand-bag.  Expose  the 
skull  as  already  described.  Apply  the  chisel  nearly  parallel  to  the  plane  of  the 
skull,  and  by  careful  use  of  the  mallet  make  it  cut  a  narrow  groove  in  the  bone. 
The  groove  is  gradually  deepened  until  the  inner  table  is  divided.  Those  skilled 
in  the  use  of  the  chisel  for  this  purpose  can  remove  or  reflect  a  large  piece  of  skull 
in  a  surprisingly  short  space  of  time.  The  chisel  is  very  useful  in  operating  in 
cases  of  fracture,  especially  of  fissured  fractures,  where  it  is  desired  to  shave  away 
jagged  and  injured  portions  of  bone.  In  the  formation  of  trap-door  openings 
through  the  skull,  the  chisel  was  the  original  instrument  employed. 


lO 


THE    SKULL  AND    THE    BRAIN. 


(C)  Gigli  Wire  Saw. — It  is  desired  to  remove  a  large  area  of  skull  in  one 
piece.  Expose  the  skull  by  a  U-shaped  incision  of  appropriate  size.  At  each 
of  the  four  corners  of  the  area  to  be  removed  perforate  the  skull  with  a  small 
trephine  or  a  Doyen's  perforator.  Doyen's  perforator  is  a  very  efficient  and 
safe  instrument,  most  conveniently  operated  by  a  brace  (Fig.  1 1).  Before  apply- 
ing the  perforator  the  outer  table  of  the  skull  ought  to  be  drilled  so  as  to  permit 
the  rounded  perforator  to  bite.  With  a  dural  separator,  separate  the  dura  from 
the  skull  along  a  line  stretching  from  one  trephine  opening  to  another.  Intro- 
duce an  appropriately  shaped  grooved  director  to  take  the  place  of  the  dural 
separator.  Pass  a  Gigli  wire  saw  along  the  grooved  director  and  leave  the 
director  in  place  to  protect  the  dura.     With  the  wire  saw  divide  the  skull  from 


Fig.  ii.~(StilIe.) 


within  outwards.  Remove  the  director.  Repeat  the  procedure  until  the 
desired  area  of  bone  is  entirely  detached.  The  Gigli  vnre  saw  is  an  excellent 
instrument  for  use  in  the  formation  of  trap-door  openings  through  the  skull. 

(D)  Forceps. — After  perforating  the  skull  as  described  in  the  preceding 
paragraph,  one  may  divide  the  bone  between  the  perforations  with  bone-cutting 
forceps,  e.  g.,  Keen's  or  DeVilbiss'  (Fig.  lo),  and  attain  the  same  result  as  when 
the  Gigli  wire  saw  is  employed. 

(E)  Electric  Saws,  etc. — Circular  saws  and  drills  driven  by  the  surgical 
engine  are  used  by  some  busy  hospital  surgeons  as  a  means  of  quickly  opening, 
the  cranium.  They  are  rarely  used  in  private  practice,  are  useful  but  expen- 
sive luxuries,  and  any  full  description  of  their  application  would  be  out  of 
place  in  a  work  such  as  this. 


MULLER-KONIG    OPERATION.  II 

In  all  the  methods  of  opening  the  cranial  vault  which  have  thus  for  been 
described  the  bone  is  removed  over  a  greater  or  less  area.  Is  it  necessary  to 
close  this  defect  by  anything  more  than  replacement  of  the  reflected  scalp? 
When  the  scalp  is  replaced,  in  time  the  bone  defect  becomes  filled  with  exceed- 
ingly hard  and  strong  fibrous  tissue  sufficient  to  protect  the  cerebral  contents 
from  injury  by  ordinary  violence.  To  prevent  the  formation  of  adhesions  be- 
tween the  scalp  and  the  cerebral  contents  many  surgeons  are  in  the  habit  of  inter- 
posing between  them  divers  smooth  aseptic  materials  cut  to  such  a  shape  that 
they  will  fit  into  the  cranial  defect.  Of  these  materials,  mention  may  be  made 
of  gold-foil,  celluloid,  thin  rubber  tissue,  the  membrane  which  lies  between  the 
shell  and  white  of  a  hen's  egg,  etc.  If  the  wound  remains  aseptic,  these  foreign 
bodies  will  lie  in  place  indefinitely.  Their  use  is  particularly  indicated  after 
operations  for  epilepsy,  but  in  the  ordinary  routine  of  cerebral  surgery  the 
author  has  distinct  doubts  as  to  their  value. 

Carl  Beck's  method  of  using  the  temporal  fascia  maybeemployed(seep.  45). 

Macewen  fills  up  the  osseous  defect  with  the  fragments  of  bone  removed. 
These  he  arranges  all  over  the  exposed  dura  like  a  tesselated  pavement.  The 
larger  fragments  or  buttons  of  bone  he  breaks  into  small  pieces  before  implanting 
them.     Excellent  results  have  attended  this  procedure. 

Instead  of  the  fragments  of  bone  removed,  decalcified  bone  chips  or  particles 
of  bone  obtained  from  other  patients  or  animals  have  been  successfully  implanted. 

Osteoplastic  measures  have  been  devised  to  close  defects  in  the  skull  with 
bone.  Mijller,  Konig  and  others  have  formed  flaps  consisting  of  the  scalp 
and  the  outer  table  of  the  skull,  and  with  these  have  covered  the  defect. 

MULLER-KONIG  OPERATION. 

Step  I. — Expose  the  cranial  defect  (O,  Fig.  12)  by  reflecting  the  skin-perios- 
teal  flap  ABC.  Excise  all  scar  tissue  from  the  cranial  defect  and  freshen  the 
edges  of  the  bone. 

Step  2. — Outline  and  reflect  the  flap  DEE.  In  forming  this  flap  cut  away 
with  the  chisel  a  portion  of  the  outer  table  of  the  skull  (G).  The  portion  of  bone 
G  is  an  integral  part  of  the  flap  DEF,  and  is  of  size  and  shape  suitable  to  be 
inserted  into  the  cranial  defect  (O). 

Step  3. — Insert  the  graft  G  into  the  defect  O,  and  suture  the  edges  of  flap 
DEF  to  the  bed  from  which  flap  ABC  was  raised. 

Step  4. — Implant  flap  ABC  in  the  bed  from  which  flap  DEE  was  raised. 

The  operation  may  be  modified  by  exposing  the  whole  area  ACDE  by 
raising  a  flap  of  scalp  without  periosteum  and  then  filling  the  defect  O  by  bone 
taken  from  the  area  H  attached  to  the  periosteum  and  not  to  the  scalp. 

Macewen  has  long  recognized  the  importance  of  closing  cranial  defects; 
most  other  surgeons  were  later  in  doing  so,  and  many  to-day  are  skeptical  or 
disbelieve  in  its  necessity.  The  later  results  in  cases  of  skull  fractures  treated 
in  Korte's  clinic  support  Macewen's  ideas  forcibly  (p.  15).  Stieda  ("Archiv. 
fiir  klin.  Chir.,"  Ixxvii,  532)  formulates  the  following  rules: 


12 


THE   SKULL  AND   THE   BRAIN. 


1.  If  the  wound  can  be  rendered  and  kept  aseptic,  close  the  defect  at  once  by 
implantation  of  the  fragments  removed  (Macewen's  method). 

2.  If  the  wound  is  healed — do  not  wait  for  the  appearance  of  epilepsy  but 
excise  the  scar  tissue  from  the  cranial  defect  and  repair  it  by  the  Miiller-Konig 
osteoplastic  method. 

Temporary  Osteoplastic  Opening  of  the  Skull.  Opening  of  the  Skull 
by  Means  of  a  "Trap-door." — This  method  is  of  much  use  when  the  opera- 
tion is  exploratory  or  is  undertaken  for  the 
removal  of  tumors  or  of  the  Gasserian 
ganglion. 

Method  I. — Make  a  U-shaped  incision 
through  the  scalp  around  the  area  to  be 
explored.  Attend  to  hemostasis.  With 
chisel  and  mallet  divide  the  bone  along  the 
line  of  the  skin-incision.  It  is  often  recom- 
mended that  the  bone-incision  be  made 
obliquely  in  such  a  manner  that  less  of  the 
inner  table  of  the  skull  is  removed  than  of 
the  outer,  so  that  when  the  flap  of  bone  is 
replaced  there  will  be  no  opportunity  for  it 
to  become  depressed.  This  precaution  is 
entirely  unnecessary.  The  flap  outlined  by 
the  U-shaped  incision  of  scalp  and  bone  is 
reflected.  To  do  this  it  is  necessary  and 
easy  to  fracture  the  bone  transversely  at  the 
pedicle  of  the  flap.  Very  large  trap-door 
openings  may  be  made;  especially  are  such 
useful  when  the  operation  is  for  the  exposure 
of  a  tumor. 

Method  II. — This  method  is  exactly  that 
described  in  the  Hartley-Krause  operation, 
page  67.  Figures  9  and  20  show  the  appear- 
FiG.  12.  ance  of  a  trap-door  opening  in  the  skull. 


CLOSURE  OF  THE  SCALP  WOUND. 


The  scalp  wound  is  closed  by  sutures.  The  author  always  prefers  to  intro- 
duce as  few  sutures  as  possible,  because  there  is  little  tendency  to  retraction,  and 
in  this  locality  especially,  any  fluids  which  may  be  thrown  out  in  the  wound  are 
very  much  better  soaked  up  in  the  dressings  than  retained  beneath  the  scalp.  If 
few  stitches  are  used,  drainage  is  unnecessary  even  when  thorough  cleansing  of 
the  wound  has  been  impossible,  except  in  the  presence  of  pus,  or  when  a  large 
cavity  has  been  left  after  removal  of  tumor,  etc.  Drainage  of  the  wound  by  a 
strip  or  wick  of  iodoform  gauze  has  proved  extremely  unsatisfactory  to  the  author; 


HEMORRHAGE. 


13 


the  gauze  has  almost  always  acted  as  a  plug  instead  of  a  drain.  Of  course,  where 
more  extensive  drainage  or  packing  is  indicated,  gauze  properly  introduced  acts 
ideally.  In  suitable  cases  drainage-tubes  of  rubber,  glass  or  decalcified  bone 
(chromicized)  are  to  be  employed. 

After  closing  the  wound  apply  the  usual  dressings.  These  are  most  con- 
veniently held  in  place  by  a  starch  bandage. 

HEMORRHAGE  FROM  THE  MIDDLE  MENINGEAL  VESSELS. 

The  middle  meningeal  artery  enters  the  cranium  through  the  foramen  spino- 
sum,  usually  accompanied  by  two  veins.  It  divides  into  an  anterior  and  a 
posterior  branch,  which  ramify  in  all  directions  over  the  dura.  Meningeal 
hemorrhage  is  usually  accompanied  by  fracture  of  the  skull,  but  as  it  sometimes 
is  caused  by  violence  which  does  not  injure  the  bone,  and  even  by  contrecoup, 
the  operative  treatment  of  the  latter  class  of  cases  must  be  considered  separately. 

I.  When  focal  symptoms  permit  the  determination  of  the  site  of  the  bleeding, 
the  indications  for  treatment  are  exceedingly  simple.     Trephine  the  skvdl  at  the 


7  W- 


Fig.  13. — Exposure  of  Middle  Meningeal  Artery. — {Esmarch  and  Kowalzig.) 

site  of  the  hemorrhage.  A  tough,  dark-colored  clot  will  be  found.  This  must 
be  removed  wdth  forceps,  probe,  spoon,  and  stream  of  hot  water.  Probably  the 
trephine  opening  will  require  enlargement;  possibly,  a  second  opening  may 
be  required,  as  extradural  clots  are  frequently  very  extensive.  If  active  bleed- 
ing continues,  search  for  its  soiirce  by  enlarging  the  trephine  opening  with 
forceps  or  making  another  opening  as  may  be  required.  Ligate  the  vessel. 
Examine  the  dura  carefully  for  signs  of  injury.  If  that  structure  is  torn,  cleanse 
the  wound  from  blood-clots  and  close  it  with  fine  sutures.  For  suturing  the 
author  prefers  fine  silk  or  celluloid  hemp  to  catgut,  merely  because  the  former 
are  so  thin  that  they  can  be  readily  threaded  on  very  small  needles.  If  the  dura 
be  found  distended  and  discolored,  or  pulsation  is  absent  showing  that  subdural 
hemorrhage  is  probably  present,  carefully  incise  that  membrane,  remove  blood- 


14 


THE    SKULL  AND    THE    BRAIN. 


clot,  stop  bleeding,  and  close  the  dural  wound.  After  the  removal  of  extradural 
clots  the  dura  soon  becomes  pushed  up  against  the  skull  in  its  normal  position, 
and  the  external  wound  may  be  closed  without  drainage. 

II.  In  the  absence  of  distinct  focal  symptoms  the  trephine  must  be  applied 
somewhere  along  the  course  of  the  artery  so  that  further  bleeding  may  be  stopped 
and,  what  is  of  greater  importance,  an  opportunity  may  be  obtained  to  explore 
for  and  remove  the  blood-clot.  Roswell  Park  writes:  "Vogt  and  Beck  have 
suggested  trephining  at  a  point  one  and  a  half  inches  above  the  zygoma  and  the 
same  distance  behind  the  angle  of  the  orbit.  An  inch  trephine  at  this  point  is 
sure  to  expose  the  anterior  branch  of  the  middle  meningeal  artery.  Neverthe- 
less, the  removal  of  the  clot  which  causes  the  compression  is  much  more  impor- 


FiG.  14. — Exposure  of  Middle  Meningeal  Artery. 
a,   b.     Base  line  from  lower  margin  orbit  through  external  auditory  meatus,     c,   d. 
Parallel  to  a  b,  from  upper  margin  orbit,  backwards,     e,  f.  Perpendicular  to  a  b,  and  about 
I    1/2    inches   posterior  to  external  angular  process,     g.  h.  Perpendicular  to  a  b,  and  im- 
mediately posterior  to  mastoid. — {Esmarch  and  Kowalzig.) 

tant  than  merely  finding  the  artery.  Kronlein  has  made  the  suggestion  of  tre- 
phining twice,  if  necessary,  in  those  cases  in  which  the  chance  of  finding  the  clot 
is  good.  He  divides  these  hematomata  generally  into  three  classes:  (i)  fronto- 
temporal;  (2)  temporo-parietal;  (3)  parieto-occipital.  He  suggests  trephining 
over  the  artery  first,  and  then,  if  no  hematoma  be  found  and  the  indications 
still  point  to  meningeal  hemorrhage,  to  trephiiie  again  just  below  the  parietal 
eminence,  because  an  opening  in  this  position  would  expose  either  of  the  latter 
classes  of  blood  tumors."     (See  Cushing's  decompressive  operation.) 

Figures  13  and  14  are  self-explanatory. 

Steiner  has  made  a  careful  study  of  the  surgical  anatomy  of  the  middle 
meningeal  artery,  and  as  a  result  has  worked  out  the  following  method  of 
reaching  the  vessel. 

(A)  (1)  Draw  a  line  from  the  middle  of  the  root  of  the  nose  to  apex  of  the 


FRACTURES    OF    SKULL.  I5 

mastoid  process.  (2)  From  the  root  of  the  nose  draw  a  line  backwards  parallel 
to  a  line  drawn  from  the  lower  margin  of  the  orbit  through  the  middle  of  the 
external  auditory  meatus.  (3)  Bisect  the  first  line  by  one  drawn  at  right 
angles  to  it. 

Where  the  third  or  vertical  line  crosses  the  second  (i.  e.,  that  parallel  to  the 
base  line  of  the  skull)  is  the  point  to  trephine  when  searching  for  the  anterior 
branch  of  the  artery. 

(B)  To  reach  the  posterior  branch  of  the  middle  meningeal  artery,  trephine 
at  the  point  where  a  line  drawn  directly  backwards  from  the  root  of  the  nose  is 
crossed  by  a  line  drawn  at  right  angles  to  it  from  the  apex  of  the  mastoid  process. 

OPERATING  FOR  FRACTURES  OF  THE  CRANIAL  VAULT. 

In  cases  of  compound  or  open  fracture,  the  wound  in  the  scalp  may  be  en- 
larged, so  .as  to  expose  the  skull,  or,  if  more  convenient,  the  scalp  may  be 
reflected  by  the  usual  U-shaped  incision,  as  is  done  in  simple  fractures. 

I.  Depressed  Fracture. — The  principle  to  be  followed  is  to  elevate  the 
depressed  bone,  remove  all  dirt,  remove  all  sharp  spicules,  stop  bleeding,  and 
leave  everything  in  the  best  possible  condition  for  healing. 

If  beside  the  depression  there  is  a  sufficiently  large  hole  in  the  skull,  the  de- 
pressed bone  may  be  elevated  or  removed  by  means  of  periosteal  elevators, 
necrosis  forceps,  or  rongeurs.  It  is  imperative,  especially  in  compound  frac- 
tures, to  make  an  opening  in  the  skull  large  enough  to  demonstrate  the 
absence  of  dirt  and  hemorrhage.  Failure  to  attend  to  this  may  be  disas- 
trous; the  extra  work  involved  in  doing  it  does  no  harm.  If  no  opening  of 
sufficient  size  exists  in  the  skull  beside  the  depression,  it  is  necessary  to  make 
one.  This  is  usually  done  with  the  trephine.  Apply  the  centre  pin  of  the 
trephine  to  the  solid  skull  beside  the  depression.  Part  of  the  cutting-edge  of 
the  instrument  overlaps  the  fracture,  but  most  of  it  lies  on  the  unfractured 
bone.  Remove  a  button  of  bone.  In  operating  do  not  exert  any  pressure 
on  the  fractured  fragments  of  bone  lest  injury  to  the  cranial  contents  result. 
Remove  or  elevate  the  depressed  bone.  Remove  blood-clot  and  foreign 
material.  Stop  bleeding.  If  desired,  the  fragments  of  bone  may  be  cleansed 
and  returned  if  conditions  are  favorable.*  If  the  dura  mater  is  torn,  it  must 
be  cleansed  and  sutured.  In  severe  injuries  the  brain  itself  is  often  much 
lacerated.  The  cerebral  wound  must  be  cleaned  by  gentle  irrigation  with 
hot  water  and  loose  fragments  of  brain  removed.  Bleeding  must  be  stopped 
by  ligature,  application  of  hot  water,  or  packing  with  gauze.     The  divided 

*  Brewitt  ("Archiv  fiir  klin.  Chir.,"  Ixxix)  studied  the  late  results  of  Korte's  cases  of 
complicated  fracture  of  the  skull.  Of  thirty-eight  patients  treated  by  reimplantation  of  the 
Sone  twenty-four  remained  in  good  health,  two  had  slight  and  two  such  severe  disturbances 
that  they  were  unable  to  work.  None  were  epileptic.  Three  out  of  four  cases  treated  by  a 
secondary  plastic  operation  were  in  good  health,  one  had  considerable  trouble.  Out  of  thirty 
cases  where  the  skull  was  left  open  only  nine  remained  in  good  health;  two  had  slight,  one 
severe  disturbances;  one  had  epilepsy;  eight  died  from  the  injury;  nine  cases  could  not  be 
traced. 


i6 


THE    SKULL  AND   THE   BRAIN. 


dura  must  be  sutured,  leaving  an  opening  for  drainage  or  for  the  gauze  pack- 
ing, and  the  external  wound  partially  closed.  When  the  dura  is  destroyed  to 
an  extent  that  its  closure  becomes  impossible,  it  is  wise  to  cover  it  with  some 
smooth  aseptic  material,  such  as  gold-foil,  rubber  tissue,  or  the  like,  unless 
drainage  is  necessary.  Schulze-Berge  has  covered  the  dural  defect  by 
splitting  the  neighboring  dura  into  two  layers  from  the  outer  of  which  he 
formed  a  flap  sufficient  to  fill  the  defect.  When  a  drain  is  required,  the  part  of 
the  brain  bereft  of  dura  must  be  left  largely  to  itself.  In  one  case  of  the  writer's 
where  there  was  much  destruction  of  brain  and  dura  and  the  wound  was  infected 
the  patient  recovered  perfectly  in  spite  of  the  appearance  of  a  hernia  cerebri. 

The  patient  was  seen  several  years  after 
the  accident  and  enjoyed  perfect  health. 
Twelve  years  later  epilepsy  developed. 

When  the  fracture  is  situated  over  the 
longitudinal  sinus  the  sinus  is  liable  to  be 
wounded.  Bleeding  can  commonly  be 
controlled  by  means  of  packing.  Wounds 
of  the  sinus  have  been  sutured  but  its 
stiff  hard  walls  do  not  lend  themselves 
easily  to  direct  suture. 

Revenstorf  ("  Centralblatt  fur  Chir.," 
Sept.  21,  1907)  recommends  the  insertion 
of  a  suture  such  as  is  sufficiently  shown 
in  Fig.   15.      The  stitch  seems  as  if   it 
would  be  inefficient  but  the  blood  pressure 
in  the  sinus  is  so  low  that  the  pressure 
exerted  by  the  suture  suffices. 
2.  Fissured  Fractures. — When  the  fracture  consists  of  a  fissure  involving 
both  tables  of  the  skull,  the  dangers  to  be  combated  are:     {a)  In  compound  frac- 
tures, dirt,     {b)  Intracranial  hemorrhage,     (c)  Separation  of  spicules  from  the 
internal  table  and  injury  to  the  brain  from  them. 

These  dangers  are  met  as  follows:  In  compound  fracture,  that  portion  of  the 
fissure  near  the  scalp  wound  must  be  treated  on  the  lines  laid  down  for  depressed 
fracture,  and  the  rest  of  the  fissure  treated  as  if  the  fracture  was  of  the  simple 
variety.  In  simple  fracture  the  fissure  should  be  exposed,  and  with  a  small 
trephine,  rongeurs,  or  chisel  the  skull  removed  at  various  points  along  the  line 
of  fissure  sufficiently  to  permit  the  surgeon  to  satisfy  himself  as  to  the  absence 
of  hemorrhage  or  of  the  penetration  of  the  brain  by  spicules  of  bone. 

When  the  fissure  does  not  involve  the  inner  table  of  the  skull,  as  demon- 
strated by  probing  with  the  blunt  end  of  the  needle  it  is  to  be  left  undisturbed, 
unless  in  the  neighborhood  of  a  wound  of  the  scalp.  When  exposed  to  dirt, 
as  is  always  the  case  in  compound  fractures,  the  fissure  should  be  cleaned  by 
shaving  its  edges  with  a  sharp  chisel.  Fissured  fractures  are  usually  met  with 
radiating  from  other  fractures  of  the  cranial  vault. 


Fig.  15. — X,  Longitudinal  sinus  with  rent 
in  it;  5,  S,  sutures;  D,  D,  dura. 


1 


FRACTURES    OF    SKULL.  I7 

All  fractures  of  the  cranial  vault  ought  to  be  subjected  to  exploratory  op  ra- 
tion whether  they  are  depressed  or  not. 

Fractures  of  the  base  of  the  skull  when  they  demand  operation  do  so  on 
account  of  secondary  complications  such  as  hemorrhage  and  more  especially 
infection.  The  operation  consists  in  exposure  (and  if  necessary  incision)  of 
the  meninges  low  down.  The  middle  fossa  is  the  one  most  commonly  affected 
and  may  be  reached  by  Cushing's  decompression  operation.  In  an  exhaustive 
paper  ("Annals  of  Surg.,"  June,  19 10)  Ransohoff  comes  to  the  following 
conclusions: 

"  I.  There  will  always  be  a  large  mortality  connected  with  basal  fractures — 
death  resulting  from  primary  shock,  brain  laceration  or  hemorrhage.  Thirty- 
seven  per  cent,  of  the  fatal  cases  die  within  six  hours  or  less,  and  56  per  cent, 
die  within  twelve  hours.  It  is  not  probable  that  the  mortality  of  this  class  of 
cases  can  ever  be  reduced  with  or  without  operation.  They  are  primarily 
fatal. 

"  2.  Twenty-three  per  cent,  of  the  fatal  cases  die  during  the  second  twelve 
hours  of  the  first  day  and  6  per  cent,  die  during  the  second  day.  They  are  the 
cases  in  which  the  coma  is  not  profound,  in  which  the  pupils  are  not  fixed,  in 
which  the  breathing  is  not  stertorous,  and  in  which  there  is  not  complete  muscu- 
lar relaxation.  With  a  slow  full  pulse  and  lumbar  puncture  indicating  hemor- 
rhage and  increase  of  intracranial  pressure,  a  trephining  operation  is  in- 
dicated.    In  the  doubtful  cases,  an  operation  is  indicated. 

"3.  In  this  class  of  cases,  where  facilities  for  the  major  operation  of  trephin- 
ing are  not  at  hand,  repeated  lumbar  punctures  should  be  essayed.  This  pro- 
cedure may  be  destined  to  take  the  place  of  decompressive  operations. 

"  4.  There  is  a  large  group  of  cases  in  which  there  is  complete  consciousness 
or  in  which  there  is  a  somnolence  or  milder  degree  of  coma,  and.  in  which  the 
concomitant  symptoms  do  not  indicate  a  grave  intracranial  trauma  either  to 
the  brain  or  its  vessels.  The  pupils  though  uneven,  react;  involvement  of  one 
or  more  cranial  nerves  may  be  evident.  The  symptoms  singly  or  collectively 
are  not  ominous  at  any  time.  Eighty  per  cent,  of  this  class  of  cases  have  a 
tendency  to  get  well  with  or  without  operation.  They  should  not  be  operated 
on  unless  the  symptoms  indicate  an  increase  of  intracranial  pressure  from 
hemorrhage  or  beginning  cerebral  edema,  or  distinct  localizing  (cortical) 
symptoms. 

"5.  There  is  a  distinct  class  of  cases  in  which  operation  is  indicated.  They 
are  cases  which  seemingly  not  severe  in  the  beginning  grow  progressively  or  sud- 
denly worse,  showing  signs  of  increased  intracranial  pressure.  Decompressive 
operation  may  save  a  considerable  proportion  of  them. 

"6.  It  has  yet  to  be  determined  where  the  trephining  should  be  done  to  ob- 
tain the  best  results.  Since  most  fractures  involve  the  anterior  or  the  middle 
fossa,  subtemporal  trephining  is  doubtless  the  precedure  oftenest  indicated. 
When,  however,  an  hematoma  in  the  mastoid  or  occipital  region  indicates  an 
involvement  of  the  posterior  fossa,  the  operation  should  be  subtentorial.     To 


I»  THE   SKULL  AND    THE    BRAIN. 

relieve  the  subtentorial  tension  by  an  opening  made  in  the  temporal  region  is 
illogical  and  may  be  dangerous.  I  attempted  it  recently  in  a  cerebellar  tumor 
the  site  of  which  could  not  be  determined.  The  patient  succumbed  within 
two  weeks  with  symptoms  of  bulbar  paralysis." 

REMOVAL  OF  TUMORS  FROM  THE  BRAIN. 

Description  of  the  methods  of  diagnosing  and  locating  tumors  of  the  brain 
would  be  out  of  place  in  this  work.  The  diagram  (Fig.  i6)  here  presented  is 
merely  meant  to  act  as  a  graphic  reminder  of  the  generally  accepted  position 
of  some  of  the  chief  centres.  Sherrington  and  Griinbaum  find  that  in  monkeys 
all  the  motor  centres  are  anterior  to  the  fissure  of  Rolando.  F.  Krause  ("Die 
deutsche  Klinik,"  viii,  961)  has  substantiated  these  findings  in  man.  Fig.  17 
represents,  on  the  left  hemisphere,  the  results  of  Krause's  investigations  in 


Fig.  16. 


twelve  operations.  J.  C.  DaCosta  and  others  agree  with  Sherrington's  views. 
It  is  necessary,  however,  to  study  the  relations  which  the  sulci  and  convolutions 
of  the  brain  bear  to  certain  landmarks  on  the  skull,  so  that  it  may  be  possible 
to  expose  the  brain  at  the  desired  spot.        , 

The  simplest  and  most  easily  remembered  means  of  finding  the  fissure  of 
Rolando  is  that  devised  by  Bennet  (Fig.  18).  At  right  angles  to  the  sagittal 
suture  draw  two  parallel  lines,  the  anterior  of  which  (c-d)  runs  along  the  anterior 
margin  of  the  external  auditory  meatus;  the  posterior  (e-f)  touches  the  posterior 
margin  of  the  mastoid  process.  These  two  lines  will  be  about  two  inches  apart. 
On  the  anterior  line  take  a  point  (g)  two  inches  above  the  external  auditory 
meatus,  and  form  it  draw  a  line  (g-e)  upwards  and  backwards  to  the  point  where 
the  posterior  line  meets  the  sagittal  suture.  This  oblique  line  is  about  three 
and  three-quarter  inches  in  length  and  corresponds  to  the  Rolandic  fissure. 

The  simplest  means  to  find  the  point  of  bifurcation  of  the  Sylvian  fissure  is 
the  following  (Esmarch):     Draw  a  line  one  and  one-half  inches  above  and 


TOPOGRAPHY. 


19 


parallel  to  the  zygoma.  Draw  a  vertical  line  three-quarters  of  an  inch  posterior 
to  the  frontal  process  of  the  malar.  These  two  lines  cross  at  a  point  correspond- 
ing to  the  bifurcation  of  the  Sylvian  fissure.     Vogt's  method  of  finding  the  same 


fxtcnsion  end 

Inward  Rotation 

foot 


Elevation,  Abduction 
Arm 


of  Ike  4   [flexion 
last  finyrs  {Ext  ension 

.     .      1  Extension 
index  [frj^,„„ 

£xlensioD  little  finjer 


Upperi  Lover  Eyelids 
Anjie  of  Mouth 

Zygomatic  Muscles  and 
levator  labii  sup. 

Masseter 


Ulnar  flexion  '\ 
Volarflexion  (  ^,  ■  , 
■Radial  flexion  <  ""''"' 
'Ptrsal  flexion) 
'strong  flexion\ 
Extension        irh„^k. 
Opposition     Uhumb 
3p«.im  ) 


Ext.  pterygoid 


Fig.  17. 


Fig.  18. — Bennet's  Method  Shown  on  the  Right;  Thane's*  on  the  Left.- 
{Esmarch  and  Kowalzig.) 


spot  is  more  easily  remembered.  The  desired  position  is  two  finger-breadths 
above  the  zygoma  and  one  thumb's  width  behind  the  frontal  process  of  the 
malar  (Fig.  13). 

A  more  elaborate  system  for  finding  the  cortical  centres  is  that  of  Chiene 

*Thane's  Method.— Bislw  the  line  a-b  (Fig.  17)  from  the  root  of  the  nose  to  the  external 
occipital  protuberance.  Take  the  point  e,  three-fourths  of  an  inch  posterior  to  the  middle 
point  of  a-b.  A  line  drawn  forwards  and  outwards  from  e,  at  an  angle  of  67  degrees  to  a-b, 
corresponds  to  the  fissure  of  Rolando. 


20 


THE   SKULL  AND   THE   BRAIN. 


("Sajous'  Annual,"  1895)  (Fig.  19):  "Shave  the  head  and  find,  in  the  median 
line  of  the  skull,  between  the  glabella  (G)  and  the  external  occipital  protuberance 
(O),  the  following  points:  The  mid-point  (M),  the  three-fourths  point  (T), 
and  the  seven-eighths  point  (S).  Find  also  the  external  angular  process  (E) 
and  the  root  of  the  zygoma  (P)  immediately  above  and  in  front  of  the  external 
auditory  meatus.  Having  found  these  five  points,  join  EP,  PS,  and  ET. 
Bisect  EP  and  PS  at  N  and  R;  also  bisect  AB  at  C  and  draw  CD  parallel  to 
AM.  The  pentagon  (ACBRPN)  corresponds  to  the  temporo-sphenoidal  lobe, 
with  the  exception  of  its  apex,  which  is  a  little  in  front  of  N.  MDC A  corresponds 
to  the  Rolandic  area  containing  the  fissure  of  Rolando,  the  ascending  frontal 
and  the  ascending  parietal  convolutions.  A  is  over  the  anterior  branch  of  the 
middle  meningeal  artery  and  the  bifurcation  of  the  Sylvian  fissure;  AC  follows 


Fig.  19. 

its  horizontal  limb.  The  lateral  sinus  at  its  highest  point  touches  the  line 
PS  at  R.  MA  corresponds  to  the  precentral  sulcus,  and,  if  it  be  trisected  at 
K  and  L,  these  points  will  correspond  to  the  origins  of  the  superior  and  inferior 
frontal  svdci.  The  supramarginal  convolution  lies  in  the  triangle  HBC.  The 
angular  gyrus  is  at  B." 

Having  determined  by  measurement,  etc.,  the  point  at  which  removal  of 
bone  will  expose  the  tumor,  mark  that  point  on  the  scalp,  with  iodine,  nitrate  of 
silver,  the  point  of  a  cautery,  or,  what  is  far  better,  puncture  the  scalp  with  a 
small  drill  which  at  the  same  time  marks  the  outer  table  of  the  skull.  If  it 
seems  proper,  any  desired  areas  of  the  skull  may  be  mapped  out  by  a  series  of 
drill  marks. 

Step  I. — Reflect  the  scalp  and  open  the  skull  as  already  described.  Gener- 
ally one  of  the  osteoplastic  or  trap-door  openings  is  best.     If  the  patient  is  weak 


TUMORS    OF    BRAIN. 


21 


Fig.  20. 
{Krause~Die  Deutsche  Klinik.) 


TUMORS    OF   BRAIN.  23 

or  if  there  has  been  much  loss  of  blood  and  shock  sustained  during  this  step 
the  operation,  attend  to  hemostasis,  apply  dressings,  and  defer  further  in 
proceedings,  for  a  few  days.  If  the  tumor  cannot  be  removed,  the  mere 
opening  of  the  skull  often  relieves  distressing  symptoms,  e.  g.,  agonizing 
headache. 

Step  2. — Examine  the  exposed  cranial  contents  both  by  inspection  and  palpa- 
tion. In  cases  of  tumor  and  blood-clot  it  is  usual  to  notice  an  absence  of  cere- 
bral pulsation  and  the  dura  often  bulges  into  the  trephine  opening.  By  palpa- 
tion tumors  have  been  correctly  located  at  a  depth  of  one  inch  from  the  surface. 
Fig.  20  shows  the  appearance  of  a  subcortical  gliosarcoma  in  the  arm  centre, 
before  and  after  incision  of  the  meninges.  Having  recognized  and  determined 
the  superficial  boundaries  of  the  growth,  reflect  the  dura  mater  as  a  U-shaped 
flap.  If  the  dura  is  involved  in  the  growth,  part  of  it  must  be  sacrificed.  When 
encapsulated,  the  tumor  itself  is  removed  by  careful  dissection  with  blunt  instru- 
ments ;  a  plain  silver  teaspoon  is  very  useful  for  this  purpose.  Infiltrating  tumors 
are  unsuited  for  operation.  Hemorrhage  is  arrested  by  gentle  ligation  of  ves- 
sels when  this  is  possible;  by  the  application  of  gauze  pads  wrung  out  of  hot 
water  and  by  packing  with  iodoform  gauze.  The  cavity  left  in  the  brain  may 
require  drainage  by  means  of  gauze,  but  the  brain  soon  expands  and  fills  up  the 
space.  After  the  active  operation  is  completed,  close  the  wound  in  the  dura 
and  scalp,  leaving,  of  course,  an  opening  for  the  emergence  of  the  gauze.  If 
the  skull  has  been  opened  by  the  trap-door  method,  enough  bone  must  be 
emoved  from  the  flap  to  permit  of  proper  drainage.  When  a  portion  of  the 
dura  mater  has  been  excised,  it  is  well  to  protect  the  brain  by  the  application  of  a 
layer  of  rubber  tissue  or  celluloid.  This  measure  is  only  feasible  if  drainage  is 
not  required.  If  the  tumor  is  cystic,  drainage  of  the  cyst  is  often  recommended 
as  sufficient,  but  in  the  author's  experience  this  has  proved  futile,  and  he  has 
been  compelled  to  operate  again  and  remove  the  cyst-walls. 

Hemorrhage  and  shock  are  not  the  only  dangers  to  be  feared  in  cranial 
operations.  It  is  well  known  that  when  the  ventricles  have  been  opened  a 
dangerous  condition  of  hyperpyrexia  may  develop.  (Bergmann,  de  Verco, 
Parry  Davenport:  quoted  by  A.  Broca,  "Precis  de  Chirurgie  Cerebrale,"  p.  323.) 
Sir  Victor  Horsley  is  of  the  opinion  that  a  thermo-taxic  centre  exists  in  the  cortex 
and  that  when  this  centre  is  injured  a  condition  of  hyperpyrexia  prevails  inde- 
pendently of  any  injury  to  the  ventricles.  One  case  seen  by  the  author,  in  which 
the  skull  was  opened  with  chisel  and  mallet  but  the  dura  was  undisturbed,  died 
in  a  state  of  marked  hyperpyrexia  before  sufi&cient  time  had  elapsed  for  septic 
changes  to  have  developed.  Another  case  reported  to  the  author  by  H.  E. 
Pearse  supports  Horsley's  contention.  This  case  was  one  of  depressed  fracture. 
At  the  operation  a  rubber  drainage-tube  was  inserted.  Immediately  the  tem- 
perature rose  to  a  high  degree.  The  dressings  were  removed  and  the  drain  was 
found  to  have  slipped  between  the  skull  and  brain.  On  removal  of  the  drain 
the  temperature  returned  to  normal  and  the  patient  made  an  uninterrupted 
recovery. 


24  THE    SKULL  AND    THE    BRAIN. 

DECOMPRESSIVE  OPERATIONS  ON  CRANIUM. 

Macewen,  Horsley  and  others  have  found  much  good  follows  exploratory 
opening  of  the  cranium  in  cases  where  tumor  was  present  but  could  not  be 
removed.  The  opening  in  the  skull  permits  the  tumor  to  grow  without  exercis- 
ing so  much  pressure  on  the  cranial  contents.  Under  such  circumstances  the 
non-elastic  dura  is  capable  of  keeping  up  injurious  pressure,  hence  when  de- 
compression is  desired  the  dura  should  be  incised  or  a  portion  of  it  be  excised. 

Operations  of  the  class  referred  to  are  known  as  "  decompressive  operations." 

Whenever  feasible  tumors  of  the  brain  should  be  removed  but  frequently 
it  is  impossible  to  find  the  location  of  the  tumor  or  to  remove  the  tumor  if  its 
precise  situation  is  known.  Under  the  above  circumstances  a  decompressive 
operation  at  the  site  of  election  is  indicated  not  as  treatment  of  the  tumor  but  as 
treatment  of  the  distressing  symptoms,  vomiting,  headache,  choked  disc,  etc. 

If  the  tumor  is  beheved  to  be  in  the  cerebrum,  Harvey  Cushing  has  shown 
that  it  is  advantageous  to  open  the  skull  under  the  temporal  muscle.  In  this 
situation  the  bone  is  thin  and  non-vascular,  while  the  temporal  muscle  and 
fascia,  if  properly  preserved,  form  an  efficient  covering  for  the  brain,  and  pre- 
vent an  undue  hernial  protrusion  in  case  there  is  a  great  increase  of  intracranial 
tension.  If  the  tumor  is  below  the  tentorium  cerebelli  the  skull  may  be 
opened  through  the  occipital  bone. 

Method  A. — Cushing's  Subtemporal  Decompression  Operation. 

Step  I. — Make  a  curved  incision  about  1/2  inch  within  the  line  of  origin  of 
the  temporal  muscle  at  the  temporal  ridge  (Fig.  21).  This  cut  should  be 
entirely  within  the  hairy  scalp.  Cut  through  the  skin  and  subcutaneous  tissue 
alone.  Reflect  the  skin  flap  downwards.  Do  not  injure  the  temporal  fascia. 
An  additional  flap  may  then  be  made  of  the  aponeurotic  layer. 

Step  2. — Split  the  temporal  fascia'in  the  direction  of  its  fibres  where  these  run 
downwards  and  forwards.  (If  the  fascia  is  split  where  its  fibres  run  vertically 
less  room  is  obtained.)     Carefully  retract  the  edges  of  the  wound  in  the  fascia. 

Step  3. — Split  the  temporal  muscle  between  bimdles  of  its  fibres.  Do  not 
cut  any  muscular  fibres  transversely.  Divide  the  periosteum  corresponding  to 
the  wound  in  the  muscle.  Separate  the  periosteum  from  the  bone  in  front  of 
and  behind  the  wound.  Retract  the  edges  of  the  wound  so  as  to  expose  the  bone 
as  thoroughly  as  possible. 

Step  4. — Penetrate  the  skull,  preferably  with  a  Doyen  bur.  With  rongeur 
forceps  remove  as  much  of  the  skull  as  possible  from  under  the  elevated  soft 
parts.  Before  attacking  any  portion  of  the  bone  be  sure  to  separate  the  under- 
lying dura  from  it.  Bleeding  from  the  bone  may  be  controlled  by  Horsley's 
wax.     An  opening  2  1/2  to  3  inches  is  easily  made  and  is  usually  sufficient. 

Step  5. — Open  the  dura  and  incise  it  radially  to  the  margins  of  the  defect  in 
the  bone.  The  anterior  incisions  should  be  made  parallel  to  the  posterior  branch 
of  the  meningeal  artery  which  may  need  ligation. 

Step  6. — Close  the  muscle  wound  with  a  few  fine  interrupted  sutures.     Care- 


DECOMPRESSIVE   OPERATIONS. 


25, 


fully  close  the  wound  in  the  temporal  fascia  with  fine  sutures  each  of  which  takes 
as  small  a  bite  of  tissue  as  is  possible.  Accurate  approximation  is  most  impor- 
tant.    Close  the  aponeurotic  layer  and  finally  the  skin  wound. 

Gushing  makes  use  also  of  the  above  method  for  explorations  of  the  temporal 
lobe  for  abscess,  etc.,  for  cases  of  meningeal  (extradural)  hemorrhage,  for  drain- 
age in  cases  of  fracture  of  the  base  of  the  skull.  Under  such  circumstances 
both  sides  of  the  skull  may  be  opened  and  the  removal  of  bone  need  not  be  so 
extensive. 


Fig.  21. — Photogil^ph  of  Patient  Four  Days  after  a  Decompressive  Operation  by 

THE  Temporal  Route. — {Harvey  Gushing.) 
To  show  line  of  incision.     He  had  previously  been  bedridden.     Complete  alleviation  of 

symptoms. 


Method  B. — Cushing's  Decompressive  Operation  Over  the  Cerebellum. 

(See  Gushing,  "Surg.,  Gyn.  and  Obstetrics,"  Oct.,  1905,  and  Spiller  and 
Frazier,  "  Journ.  Amer.  Med.  Assoc,"  Sept.,  1906.) — It  is  doubtful  whether  this 
method  has  any  advantage  over  the  subtemporal  method  as  a  decompressive 
measure  in  cerebellar  tumors.  The  difficulties  and  dangers  of  the  operation 
are  considerable.  Hemorrhage  from  the  bone  and  dura  and  especially  from  the 
veins  leading  into  the  mid-occipital  sinus,  may  be  hard  to  overcome. 

Step  I. — Make  a  curved  incision  (Fig.  23)  a  little  above  the  superior  curved 
line  of  the  occiput.     Make  a  longitudinal  median  incision  running  downwards 


26 


THE    SKULL  AND    THE    BRAIN. 


from  the  middle  of  the  curved  incision  (Fig.  23).  Reflect  downwards  and  out- 
wards the  two  triangular  flaps  of  skin  thus  outlined  until  the  upper  portion  or 
origin  of  the  flat  superficial  cervical  muscles  is  exposed.  Divide  the  muscles 
parallel  to  and  about  3/4  inch  from  their  line  of  origin.  Make  a  median  vertical 
incision  between  the  muscles  down  to  the  spines  of  the  upper  cervical  vertebrae 
and  divide  the  ligamentwn  nuchcB  in  the  middle  line.  Retract  the  soft  parts. 
Expose  the  base  of  the  occiput  by  separating  the  periosteum  from  it  and  with 
the  periosteum  separate  the  attachments  of  the  deep  muscles. 


Fig.  22. — Sketch  of  the  Intermusculo-temporal  Field  of  Operation.- 

(Harvey  Gushing.) 

Showing  exposure  with  bone  defect  partially  made. 


Step  2. — Open  the  skull  on  each  side  through  the  prominent  thin  bosses  of 
the  occiput.  Enlarge  the  openings  with  rongeur  forceps.  The  ridge  of  bone  in 
the  middle  line  must  be  attacked  vdth  great  care  because  of  the  occasional  mid- 
occipital  sinus  and  emissary  veins.  Gushing  finds  it  helpful  "to  crowd  wisps 
of  sterile  cotton  ahead  of  the  dural  separator  when  freeing  the  membranes  from 
this  mid-ridge,  a  procedure  which  necessarily  ruptures  and  blocks  these  emis- 
sary vessels  in  case  they  are  present." 

Step  3. — When  the  bone  defect  is  large  enough,  ligate  the  median  occipital 
sinus  and  excise  the  dura  corresponding  to  the  opening  in  the  bone. 

Step  4. — Close  the  wound  preferably  without  drainage.     On  account  of 


CALLOSAL    PUNCTURE. 


27 


oozing  of  blood  a  drain  of  folded  rubber  tissue  or  of  oil  silk  may  be  employed 
but  it  should  be  withdrawn  within  forty-eight  hours. 

Anton  suggested  that  in  cases  of  inoperable  or  unlocalized  brain  lesions 
(tumors,  internal  hydrocephalus,  etc.)  intracranial  pressure  might  be  lowered 
by  perforating  the  corpus  callosum,  whereby  a  free  communication  would  be 
established   between   the   ventricles   and   the   subdural   space.     If   the  intra- 


FiG.  23. — Sketch  op  thk  Field  of  Operation,  Before  Opening  the  Dura,  in  the 

Suboccipital  Procedure. — {Harvey  Gushing.) 

Note  the  high  transverse  cut  of  the  "crossbow"  incision. 

ventricular  pressure  is  above  normal  the  fluid  must  flow  out  into  the  subdural 
space  and  in  doing  so  keep  the  perforation  patent.  Experiments  made  by  Rehn 
show  that  such  a  flow  does  take  place.  The  anterior  and  middle  thirds  of 
the  corpus  callosum  form  the  best  site  for  puncture  as  it  is  thinnest  here  and  one 
or  other  of  the  lateral  ventricles  is  sure  to  be  penetrated.     A  careful  study  of 


28  THE    SKULL  AND    THE    BRAIN. 

callosal  puncture  has  been  made  by  v.  Bramann  ("Archiv  fur  klin.  Chir.," 
xc,  689)  who  operates  in  the  following  manner: 

1.  Choose  a  spot  about  one  finger-breadth  behind  the  bregma  (i  to  i  1/2  cm. 
behind  the  coronary  suture)  and  expose  the  skull  here  by  any  suitable  incision. 

2.  With  a  bur  (Doyen's,  Sudeck's)  make  an  opening  i  cm.  by  i  1/2  to  2  cm. 
through  the  skull  at  right  angles  to  the  sagittal  suture. 

3.  Note  the  longitudinal  sinus  and  at  its  margin  make  a  small  opening 
through  the  dura  mater. 

4.  Pass  a  sinus  forceps  (v.  Bramann  uses  a  special  pliable  silver  caimula  with 
a  mandrin)  along  side  the  sinus  into  the  longitudinal  fissure  where  it  meets  the 
falx.  Guided  by  the  falx  pass  the  instrument  vertically  downwards  until  it 
penetrates  the  corpus  callosum. 

5.  Open  the  blades  of  the  forceps  (or  remove  the  mandrin  from  the  cannula) 
and  permit  the  ventricular  fluid  to  escape.  Enlarge  the  callosal  opening  by 
moving  the  instrument  gently  backwards  and  forwards  (not  laterally). 

6.  Remove  the  instrument  and  close  the  wound  in  the  scalp. 

V.  Bramann  has  performed  callosal  puncture  in  twenty-two  patients  without 
a  death  attributed  to  the  operation  (cerebral  tumors  thirteen;  hydrocephalus 
eight;  epilepsy  one). 

Anton  and  v.  Bramann  believe  callosal  puncture  indicated:  i.  In  all  cases  of 
hydrocephalus  where  internal  treatment  has  failed. 

2.  In  all  cases  of  tumors  and  pseudo  tumors  of  the  brain  accompanied  by 
internal  hydrocephalus  and  choked  disc  which  threatens  blindness.   < 

3.  When  intracranial  pressure  is  so  great  as  to  interfere  with  palpation 
of  the  brain  or  with  the  removal  of  tumors,  preliminary  callosal  puncture  may 
aid. 

OPERATIONS  FOR  INFECTIVE  DISEASE  OF  THE  MIDDLE  EAR 
AND  CRANIAL  CONTENTS. 

Cerebral  abscess  is  almost  always  the  result  of  chronic  otitis  media.  Proper 
treatment  of  the  cerebral  abscess  requires  removal  of  the  original  focus  of  dis- 
ease. In  the  following  pages  the  author  makes  free  use  of  Macewen's  classical 
work  on  the  "Pyogenic  Infective  Diseases  of  the  Brain  and  Spinal  Cord."  The 
reader  is  advised  to  carefully  study  the  above  book  before  attempting  any  opera- 
tion for  cerebral  abscess.  The  present  chapter  is  only  written  in  the  hope  of 
aiding  some  practitioner  who  is  forced  to  operate  without  the  advantage  of  such 
study. 

Suppurative  disease  of  the  middle  ear  unrelieved  by  treatment  administered 
through  the  external  meatus  is  always  complicated  by  disease  of  the  mastoid. 
The  chief  indications  demanding  operation  on  the  mastoid  cells  are: 

1.  Repeated  inflammations  of  the  mastoid  antrum  and  cells  with  swelling 
over  or  fistulae  leading  into  the  bone. 

2.  Acute  inflammation  with  retention  of  pus  in  the  antrum  or  cells. 


MASTOIDITIS. 


29 


3.  The  occurrence  of  initial  symptoms  of  intracranial  involvement  asso- 
ciated with  chronic  purulent  otorrhoea. 

4.  Persistent  chronic  otorrhoea,  not  principally  due  to  the  condition  of  the 
tympanum  or  Eustachian  tube,  and  which  is  considered  by  the  aurist  otherwise 
incurable,  even  although  there  are  no  clear  indications  of  mastoid  involvement. 

5.  If  the  discharge  contain  virulent  organisms,  if  it  be  highly  offensive,  mixed 
with  osseous  debris  or  cholesteatomatous  masses,  operation  is  indicated,  as 
most  serious  intracranial  mischief  is  often  present  without  marked  mastoid 
swelling. 

The  Operation. — I.  Cleanse  the  external  and  middle  ear  as  thoroughly  as 
possible.     Shave  the  scalp  above  and  behind  the  mastoid.     Cleanse  the  skin. 

Step  I. — Place  the  patient  on  his  side  mth  the  affected  mastoid  uppermost. 
Have  the  parts  well  lighted.     Pull  forv    rd  the  external  ear.     Palpate  the  mas- 


FlG.    ^x.-  -C,  F,  E   (X).       SUPRAMEATAL   OR   MaCEWEN'S   TrIANGLE. 

A    B.  Upper  two-thirds  of  this  line  o-erlies  the  sigmoid  sinus.     C,  D.  Overlies  sigmoid 
)  '         •'  snus  from  knee  to  commencement. 


•  jostcrior  root  of  the  zygoma.  Make  a  perpendicular  cut  about  one- 
i  behind  the  posterior  border  of  the  external  bony  meatus  from  the 
posteri  jr  root  of  the  zygoma  to  a  point  about  one-third  of  an  inch  from  the  tip 
of  the  mastoi".  The  knife  penetrates  to  the  bone.  With  the  elevator  separate 
the  f  eriosteun  and  soft  structures  from  the  bone  in  front  of  the  cut  and  thus 
fully,  expose  ae  posterior  aspect  of  the  external  auditory  meatus.  Attend  to 
hemostasis. — [old  the  reflected  tissues  and  auricle  forward  with  a  sharp 
retra  ctor. 

i."  -<pserve  the  limits  of  the  suprameatal  triangle,  viz.,  the  posterior 

■tT"  zV^ma  above,  the  upper  and  posterior  segment  of  the  bony  external 

meat^is  belovlmd  an  imaginary  vertical  line  (EF,  Fig.  24)  extending  from  the 


30  THE    SKULL  AND    THE    BRAIN. 

most  posterior  portion  of  the  external  osseous  meatus  to  the  zygomatic  root, 
behind.  This  vertical  imaginary  line  is  the  base  of  the  triangle.  Observe 
the  degree  of  obliquity  of  the  posterior  wall  of  the  external  auditory  meatus  as  it 
leads  inwards  and  forwards  to  the  middle  ear.  By  the  aid  of  a  probe  observe  the 
depth  of  the  inner  wall  of  the  tympanic  cavity  from  the  level  of  the  skull. 

The  best  instrument  for  use  in  penetrating  the  bone  is  a  bur  rapidly  rotated 
by  a  surgical  engine.  One  may  conveniently  use  a  bur  operated  by  the  "brace" 
shown  in  Fig.  1 1 .  Apply  the  bur  to  the  bone  at  a  point  inside  and  beside  the  base 
of  the  suprameatal  triangle.  Penetrate  the  outer  shell  of  hard  bone.  In  some 
cases  the  whole  mastoid  is  thickened  and  sclerosed  by  disease.  With  the  bur, 
slowly  and  cautiously  advance  through  the  bone  in  a  direction  inwards  and  a 
little  forwards,  parallel  to  the  posterior  wall  of  the  external  auditory  meatus. 
Do  not  use  the  bur  as  if  it  were  a  drill,  making  a  uniform  cylindrical  perforation 
the  same  size  as  the  instrument;  this  would  be  dangerous  and  nearly  useless. 
Use  it  to  make  a  hole  in  the  mastoid  -^-ery  much  larger  than  the  instrument — 
large  enough  to  permit  of  the  continuance  of  the  work  under  the  guidance  of  the 
eye  as  well  as  of  touch.  The  -external  opening  may  safely  be  made  the  whole 
size  of  the  suprameatal  triangle.  Whenever  a  dark  spot  is  seen  on  the  cut 
surface  of  bone,  examine  it  at  once  with  a  fine  probe  or  searcher  (a  dental  probe 
is  good).  The  dark  spot  is  probabl}'  an  opening  into  one  of  the  mastoid  cells 
or  even  the  antrum;  if  the  latter,  the  probe  will  find  a  large  cavity  communicat- 
ing with  the  middle  ear.  The  depth  of  the  aiTitrum  from  the  surface  varies  from 
i/8  to  3/4  inch.  A  small  opening  havina;  been  made  in  the  antrum  and  its 
cavity  explored  with  a  probe,  bur  away  all  irs  external  wall,  remove  all  pus, 
granulation  tissue,  or  other  disease  products. 

II.  Observe  the  position  of  the  opening  between  the  antrum  and  the  middle 
ear;  the  position  of  the  facial  nerve  traversing  the  inner  half  of  the  floor  of  the 
antral  passage  obliquely  from  vdthout  inwaijds,  as  i'  -^asselinto  the  inner  wall 
and  roof  of  the  tympanum  above  the  forameti  ovale.  I  he  ne'/ve  rou^e  is  often 
indicated  by  a  cylindrical  ridge  of  bone  smcjother  an(i  denser  lan  that  in  the 
neighborhood.  If  the  position  of  the  nerv^  is  not  positively  made  out.,h.^ye 
an  assistant  observe  the  patient's  face  for  ihe  occuriience  of  twiichings  if  Xh(^ 
nerve  is  endangered  in  the  subsequent  proceedings.  In  observ ;  n  ^  t^  ■  ^  conditioii! 
of  the  tissues  deep  down  in  the  wound  light  should  be  thrown  in,  tihei  x»y  means 
of  a  head  mirror  or  of  an  electric  lamp  (with  reflector)  leld  by  an  avl  jfexamine 
the  roof  of  the  antrum  for  evidences  of  bone  disease,  If  bu  Is  of  grantlation 
tissue  sprout  from  the  roof,  examine  them;  they  may  come  from  ir^ide  tht-  ^1-  n^^ 
and  show  the  presence  and  location  of  intracranial  involvement.    I  ♦'- ' 

Step  3. — Examine  the  mastoid  cells  opened  during  exposure  <  the  ... 
if  they  are  diseased,  as  evidenced  by  the  presence  of  granulation  tfi'.e,^pu..  _ :., 
destroy  their  walls  with  the  bur,  so  that  instead  of  numerous,  iVgnlar,  spiall 
cells,  one  large  cavity  with  smooth  walls  is  formed.  Remember  ^f-  locaticj-n  of 
the  sigmoid  groove  and  sinus  (Fig.  24).  Because  of  the  sir^  it  is  wifsc  to 
open  the  mastoid  cells  by  working  from  the  antrum  downwards  id  backwfards. 


MASTOIDITIS.  31 

Never  attack  an  exposed  cell  before  thoroughly  exploring  it  with  a  probe. 
Remember  that  granulation  tissue  and  other  disease  products  may  be  con- 
tinuous from  the  middle  ear  through  the  antrum,  mastoid  cells,  sigmoid 
groove,  and  sinus  to  the  cerebellum.  If  granulations  are  found  sprouting  out 
from  the  sigmoid  groove  or  other  evidences  show  disease  in  that  locality,  do  not 
yet  attack  it.  Complete  the  thorough  cleansing  of  the  antrum  and  mastoid,  bur 
away  all  partitions,  and  leave  them  as  one  cavity  with  smooth  walls. 

Step  4. — The  middle  ear  is  diseased  and  requires  to  be  opened.  Apply  a 
small  bur  at  the  junction  of  its  roof  with  the  outer  wall  of  the  antral  passage. 
Do  not  touch  the  floor  or  inner  wall  of  the  passage  for  fear  of  injury  to  the  facial 
nerve  or  semicircular  canal.  Freely  expose  the  tympanic  attic  and  examine  its 
roof  in  the  same  way  as  the  roof  of  the  antrum  was  examined.  Examine  the 
malleus  and  incus;  if  diseased,  remove  them.  It  is  important  to  leave  the  stapes, 
if  possible ;  but  if  diseased,  it  also  must  be  removed.  If  the  mastoid,  antrum,  and 
middle  ear  are  the  only  seats  of  disease,  the  active  operation  is  ended;  the  cavity 
is  packed  with  iodoform  and  boracic  acid  (1:4)  and  with  iodoform  gauze. 
Closure  of  the  wound  is  facilitated  by  removal  of  a  portion  of  the  posterior 
bony  wall  of  the  external  auditory  meatus.     Dressings  are  applied. 

Step  5. — If  on  examination  of  the  roof  of  the  antrum  or  tympanic  cavity 
erosions  of  the  bone  exist  and  granulations  sprout  out  from  the  cranial  ca\dty, 
or  if  there  are  symptoms  of  intracranial  involvement,  active  operation  is  con- 
tinued. With  the  bur  remove  the  eroded  bone  of  the  antral  or  tympanic  roof  in 
a  direction  outwards  from  the  perforation.  If  pus  and  granulation  tissue  pre- 
sent, there  is  an  extradural  focus  which  must  be  carefully  cleansed.  Do  not 
inject  any  fluids  until  the  whole  space  between  the  dura  and  bone  has  been 
explored  and  the  presence  or  absence  of  openings  through  the  dura  made  certain. 
If  there  is  no  dural  opening,  gentle  washing  is  safe,  and  the  extradural  space 
may  be  dressed  with  iodoform  and  boracic  acid  and  iodoform  gauze.  If  there 
is  evidence  of  disease  under  the  dura,  clean  the  extradural  space  and  freely 
open  the  dura. 

Step  6.- — Pus  in  the  arachnoid  or  pia  or  on  the  surface  of  the  brain  must  be 
gently  washed  away,  and  iodoform  and  boracic  acid  powder  must  be  applied. 
If  an  abscess  exists  in  the  temporosphenoidal  lobe,  enlarge  the  opening  through 
the  roof  of  the  antrum  and  tympanic  cavity,  apply  iodoform  and  boracic  acid  to 
the  wound,  and  proceed  to  Step  7. 

Step  7. — Extend  the  cut  through  the  soft  parts  upwards  and  expose  the 
skull  above  the  ear.  Open  the  skull  with  a  small  trephine  whose  centre  pin  is 
applied  at  a  point  three-fourths  of  an  inch  above  the  posterior  root  of  the  zygoma 
and  in  line  with  the  posterior  osseous  wall  of  the  external  auditory  meatus. 
Rub  iodoform  into  the  cut  surface  of  the  bone.  Incise  the  dura.  If  necessary, 
make  a  crucial  incision.  Stop  bleeding.  If  the  abscess  is  large,  the  brain  will 
probably  bulge  and  fail  to  pulsate;  if  smaller,  neither  of  these  signs  may  be  pres- 
ent. To  explore  for  pus  use  a  trocar  and  cannula  or  a  sinus  forceps.  A 
hollow  needle  is  liable  to  become  plugged.     Introduce  the  instrument  inwards, 


32  THE    SKULL  AND    THE    BRAIN. 

downwards,  and  slightly  forwards,  so  as  to  impinge,  if  pushed  far  enough,  against 
the  cranial  aspect  of  the  roof  of  the  tympanum.  If  a  trocar  and  cannula  are 
used,  the  trocar  should  be  removed  at  every  quarter  inch  of  progress  to  see  if  pus 
escapes;  if  a  sinus  forceps,  the  blades  should  be  slightly  opened  for  the  same 
purpose.  After  pus  is  found,  remember  that  the  abscess  probably  contains 
sloughs  and  shreds  of  tissue  too  large  to  escape  through  the  cannula  and  which 
must  be  removed.  Alongside  the  cannula  introduce  closed,  narrow-bladed 
hemostatic  or  sinus  forceps;  open  the  blades  gently  and  permit  the  sloughs  to 
flow  out  between  the  blades.  If  the  sloughs  cannot  escape  by  themselves,  they 
may  be  assisted  out  by  forceps  or  spoon;  their  removal  is  of  prime  importance. 
After  removal  of  the  sloughs  replace  the  hemostatic  forceps  by  a  small  cannula. 
Through  the  mastoid  wound  and  the  opening  through  the  antral  roof  introduce 
into  the  abscess  cavity  a  cannula  at  least  one-half  as  large  again  as  that  already 
in  situ.  Be  sure  that  the  end  of  this  tube  is  in  the  cavity.  It  is  wise  to  let  the 
two  cannulas  come  in  contact.  Gently  introduce  a  stream  of  hot  water  or  mild 
antiseptic  solution  through  the  smaller  tube  and  see  that  it  all  escapes  through 
the  larger.  Lest  fluid  should  enter  the  Eustachian  tube,  fill  the  middle  ear  with 
the  iodoform  and  boracic  powder.  In  an  acute  abscess  which  has  been 
thoroughly  cleansed  of  infective  matter,  a  drainage-tube  is  of  little  value  and 
may  do  harm.  If  there  is  doubt  at  to  the  thoroughness  of  the  evacuation,  intro- 
duce a  decalcified  bone  drain  so  that  its  opening  is  just  within  the  abscess. 
Stitch  the  drain  to  the  skin.  If  the  abscess  cannot  be  properly  drained,  in  the 
above  manner,  use  a  rubber  or  glass  tube  for  from  twenty-four  to  forty-eight  hours. 
Treat  the  mastoid  opening  as  already  described  (page  31).  Close  the  temporal 
opening  with  or  without  drainage  on  ordinary  surgical  principles. 

[If  abscess  of  the  temporo-sphenoidal  lobe  exist,  without  indication  of  dis- 
ease requiring  the  mastoid  to  be  opened,  the  operation  is  carried  out  practically 
as  described  in  Step  7 ;  but  in  washing  out  the  abscess  an  escape  for  the  fluid  must 
be  provided  by  means  of  a  cannula,  at  least  half  as  large  again  as  that  through 
which  it  enters.     The  two  cannulae  lie  side  by  side.] 

Step  8. — It  has  already  (Step  3)  been  shoAvn  that  disease  of  the  sigmoid 
groove  may  be  discovered  while  the  mastoid  cells  are  being  obliterated. 
Examination  with  the  fine  probe  or  searcher  shows  that  buds  of  granulation 
tissue  coming  through  osseous  openings  are  continuous  vnth  the  same  tissue  in 
the  sigmoid  groove.  Apply  the  bur  to  the  posterior  wall  of  the  antrum  and 
with  it  remove  the  bone  horizontally  backwards  for  half  an  inch.  In  a  majority 
of  cases  this  will  open  the  greater  part  of  the  diameter  of  the  sigmoid  groove 
sinus,  after  which  it  may  be  opened  above  and  below  that  point  as  may  be  indi- 
cated. The  anterior  knee  of  the  sinus  is  situated  from  one-eighth  to  a  quarter  of 
an  inch  behind  the  base  line  of  the  suprameatal  triangle  (Fig.  24).  If  it  seems 
necessary  to  open  the  sigmoid  sinus  to  remove  septic  blood-clot,  fully  one  inch  of 
the  sinus  ought  to  be  exposed,  vertically,  by  removal  of  bone.  Remove  any 
diseased  tissue  lying  between  the  groove  and  the  sinus.  If,  on  examination  by 
the  eye  and  the  probe,  the  disease  is  found  to  extend  through  the  bone  into  the 


MASTOIDITIS.  33 

cerebellum,  this  disease  route  must  be  followed  and  cleansed  and  any  cerebellar 
abscess  attended  to  in  the  manner  to  be  described.  If  there  is  septic  sinus 
thrombosis,  open  the  sinus  and  remove  the  filth  within  it.  After  cleansing  the 
sinus,  introduce  into  it  a  quantity  of  iodoform  and  boracic  acid  powder,  make 
the  walls  of  the  sinus  collapse,  gently  pack  the  sigmoid  groove  with  the  same 
powder,  and  loosely  pack  the  whole  cavity  with  iodoform  gauze.  If  during  the 
operation  hemorrhage  take  place  from  a  non-thrombosed  sinus,  it  may  be 
stopped,  if  slight,  by  temporary  pressure;  if  more  severe,  by  separating  the  wall 
of  the  sinus  from  the  bone  and  pushing  the  loosened  wall  inwards  by  means  of 
iodoform  gauze  packing.  In  certain  cases  Horsley  has  found  it  valuable  to 
doubly  ligate  and  divide  the  internal  jugular  vein.  This  is  intended  to  prevent 
dissemination  of  the  infective  material  throughout  the  body. 

Step  g. — In  the  preceding  step  it  has  been  shown  how  extension  of  disease 
through  the  sigmoid  sinus  to  the  cerebellum  may  be  discovered.  If  this  is  the 
case,  the  disease  is  followed  and  the  bone  between  the  sigmoid  groove  (outer 
aspect  of  the  groove)  and  the  cerebellum  is  removed  by  the  bur.  The  mem- 
branes covering  the  cerebellum  are  treated  in  the  same  manner  as  were  those 
covering  the  temporo-sphenoidal  lobe.  If  a  cerebellar  abscess  exist,  enlarge- 
ment of  the  osseous  opening  already  made  permits  of  its  evacuation  and  treat- 
ment on  the  principles  already  described. 

After-treatment. — If  there  is  no  evidence  of  petrous  or  internal  ear  disease, 
the  wounds  must  be  packed  with  iodoform  gauze  to  compel  healing  to  take  place 
from  the  bottom.  The  whole  cavity  ultimately  becomes  a  solid  mass  of  scar 
tissue.  In  the  presence  of  petrous  or  internal  ear  disease  a  seton  of  iodoform 
gauze  must  be  passed  from  the  middle  ear,  through  the  antrum  out  by  the  mas- 
toid opening.  This  gauze  seton  is  frequently  renewed  and  its  route  kept  clean, 
until  epithelium  from  the  mucous  membrane  and  the  skin  has  so  covered  the 
track  that  a  permanent  fistula  is  assured  through  which  any  discharge  from  the 
internal  ear  or  petrous  bone  may  escape.  The  formation  of  the  permanent 
sinus  may  be  hastened  by  lining  it  with  skin  grafts. 

After  the  dressings  are  applied  put  the  patient  to  bed,  and  keep  him  there 
until  the  wounds  are  completely  healed.  A  low  liquid  diet  is  recommended  for 
a  fortnight  after  cerebral  abscesses  have  been  evacuated.  The  only  peculiarity 
of  the  after-treatment  is  the  necessity  of  a  little  extra  insistence  on  quiet,  and  on 
the  observance  of  the  usual  rules  adopted  after  major  surgical  operations. 

Abscesses  in  other  localities  of  the  brain,  after  being  diagnosed  and  located, 
are  operated  upon  on  the  same  principles  as  have  been  described  in  the  preced- 
ing pages. 

OPENING  THE  MASTOID  WITH  THE  CHISEL  AND  RONGEURS. 

Undoubtedly  the  bur  operated  by  a  surgical  engine  is  the  most  elegant  instru- 
ment with  which  to  open  the  mastoid  antrum,  and  it  possesses  many  advantages 
over  the  chisel;  but  comparatively  few  surgeons  possess  the  necessary  instru- 
3 


34  THE    SKULL  AND    THE    BRAIN. 

merits  nor  are  they  convenient  to  carry  to  a  patient's  home  when  the  patient 
cannot  or  will  not  enter  a  hospital.  Most  surgeons  possess  some  dexterity  in 
the  use  of  the  chisel,  but  are  not  educated  to  the  bur,  hence  the  chisel,  and  its 
relative,  the  rongeur  forceps,  are  the  instruments  commonly  used  in  the  mastoid 
operation. 

The  operation  often  ends  immediately  after  the  mastoid  antrum  is  opened. 
This  is  improper,  as  the  antrum  is  only  one  of  many  mastoid  spaces,  any  or  all 
of  which  may  be  diseased. 

WTiiting  ("The  Modern  Mastoid  Operation"),  in  his  superbly  illustrated 
book,  shows  how  the  "air-cells"  may  extend  above  and  over  the  bony  meatus, 
and  unless  these  are  obliterated,  the  suppurative  process  is  sure  to  continue. 
The  principle  of  the  complete  operation  on  the  mastoid  is  the  obliteration  of  all 
the  mastoid  cells  and  the  removal  of  all  disease  wherever  situated,  as  described 
in  the  preceding  pages.  The  method  of  operating  usually  adopted  by  the 
author  is  much  as  follows: 

Clean  the  ear  as  well  as  possible.  Shave  and  clean  the  skin  over  and 
around  the  mastoid. 

Step  I. — Make  an  incision  parallel  to  the  insertion  of  the  auricle,  and  about 
1/4  inch  posterior  to  the  external  auditory  meatus.  The  incision  stretches  from 
just  above  the  root  of  the  zygoma  to  a  little  below  the  tip  of  the  mastoid.  Expose 
the  whole  surface  of  the  mastoid  by  reflecting  the  soft  parts  along  with  the 
periosteum.  A  second  incision  at  right  angles  to  the  first  may  be  necessary  to 
insure  exposure.  Examine  the  bone  for  points  of  necrosis  or  for  the  escape  of 
pus  at  the  vascular  orifices. 

It  is  especially  important  to  examine  the  mastoid  vein  at  its  outlet,  which  is 
usually  near  the  posterior  margin  of  the  bone.  The  vein  varies  in  size  and  may 
divide  into  several  branches  as  it  passes  through  the  skull.  As  the  vein  com- 
municates directly  with  the  sigmoid  sinus,  when  the  latter  is  thrombosed  the 
former  is  likely  to  be  in  the  same  state.  Thrombosis  of  the  mastoid  vein  is 
positive  evidence  of  sinus  thrombosis;  apparent  patency  of  the  vein  is  of  no  sig- 
nificance. Pus  oozing  from  the  mastoid  foramen  signifies  pus  situated  outside 
the  dura  in  the  cerebellar  fossa,  about  the  sigmoid  groove. 

Step  2. — Pull  the  external  ear  well  forwards  with  a  retractor.  Observe  the 
depth  and  direction  of  the  external  auditory  canal.  Beginning  at  the  upper  part 
of  the  suprameatal  triangle,  shave  off  thin  slices  of  bone  downwards  and  forwards 
towards  the  tip  of  the  mastoid,  always  hugging  the  posterior  margin  of  the  bony 
meatus.  This  shaving  is  to  be  done  with  a  chisel  or  gouge  about  1/4  inch  in 
width,  propelled  by  a  mallet.  The  chisel  must  be  held  almost  parallel  to  the 
surface  of  the  bone,  and  must  always  be  directed  downwards  and  forwards. 

The  usual  chisels  and  gouges  supplied  for  mastoid  work  are  short  and  have  thin 
shanks  and  handles.  Such  may  be  safe  and  convenient  in  the  hands  of  aurists,  but 
to  the  general  surgeon  a  chisel  with  a  handle  like  a  Macewen  osteotome,  or  even  a 
carpenter's  tool,  is  much  safer  and  more  practical.  It  is  well  to  have  a  number  of 
chisels  or  gouges  of  diflferent  sizes. 


MASTOIDITIS. 


35 


After  several  exceedingly  thin  slices  of  bone  have  been  removed,  the  diploe 
will  be  reached,  unless  there  is  much  sclerosis. 

With  a  narrow  curette  scrape  away  the  superficial  portion  of  the  diploe.  If 
pus  or  fluid  appears,  note  its  quantity,  as  this  gives  some  index  to  the  size  of  the 
cavity  from  which  it  comes;  note  also  if  the  pus  is  throA\Ti  out  in  jets  or  pulsating 
fashion,  because  such  pulsation  is  communicated  from  the  brain  and  is  almost 
absolute  proof  that  the  disease  has  penetrated  at  least  to  the  meninges.  With  a 
probe  gently  explore  the  pus-cavity  and  enlarge  the  opening  with  curette,  gouge, 
or  rongeur,  as  may  be  convenient.  Never  endeavor  to 
clean  out  a  pus-cavity  in  the  mastoid  with  the  curette 
through  a  narrow  external  opening — it  is  too  dangerous. 
If  no  pus  or  fluid  appears,  deepen  the  groove  already 
cut  in  the  bone  to  the  extent  of  1/3  inch.  If  the  sig- 
moid sinus  is  abnormally  far  forwards,  it  ought  now 
to  be  visible  as  "a  soft,  bluish-looking  structure,  very 
fluctuant  to  palpation  and  perhaps  pulsating  demon- 
strably, which  upon  gentle  pressure  of  a  probe  yields 
readily  but  does  not  bleed"  (Whiting).  When  the  sinus 
is  found  in  this  abnormal  position,  the  rest  of  the 
operation  consists  in  exposing  all  the  diseased  cavities 
and  evacuating  all  infective  material,  without  injuring 
the  sinus,  unless  that  structure  is  involved  in  the 
process.  When  the  sinus  is  not  abnormally  placed, 
proceed  wdth  the  removal  of  all  the  outer  wall  of  the 
mastoid  process. 

Step  3. — With  the  chisel  repeat  the  manoeuvres  by 
which  the  mastoid  was  originally  opened,  and  so  widen 

the  existing  opening  that  the  blade  of  a  rongeur  (Fig.  25)  ^^^  25.— Narrow-bladed 
can  easily  enter  it  and  pass  under  the  bone.     With  a       Rongeur  Forceps. 
rongeur  carefully  bite  away  the  whole  bony  outer  wall 

of  the  mastoid  process.     Never  attack  any  part  of  the  bone  before  making  sure 
that  the  sigmoid  sinus  will  not  be  injured. 

Instead  of  widening  the  original  opening  in  the  bone  vnih.  the  chisel,  the 
author  usually  inserts  into  it,  partially,  one  blade  of  a  heavy  rongeur,  the  other 
blade  of  which  rests  against  the  mastoid  farther  back.  By  exerting  a  twisting 
force  it  is  easy  to  use  the  posterior  blade  of  the  forceps  as  a  fulcrum,  and  with 
the  anterior  blade  (the  blade  engaged  in  the  bony  opening)  to  scrape  off  a  thin 
layer  of  the  cortical  layer  of  bone.  This  method  of  using  the  rongeur  is  difficult 
to  describe,  easy  and  safe  to  practise,  and  aids  materially  in  the  operation. 
When  the  mastoid  has  once  been  opened  to  such  an  extent  that  the  rongeur  can 
be  used  efficiently,  either  as  a  biting  or  as  a  scraping  instrument,  put  the  chisel 
and  mallet  aside  as  of  no  further  use.  If  much  sclerosis  is  present,  this  rule  does 
not  apply. 

Step  4. — No  attempt  has  been  made,  as  yet,  to  find  the  antrum  or  systemat- 


z^ 


THE    SKULL   AND    THE    BRAIN. 


ically  to  obliterate  the  mastoid  cells;  the  cortical  bone  has  been  removed  at  least 
to  a  large  extent;  the  diploe  has  been  but  little  disturbed.  Remember  that  the 
antrum  in  99  per  cent,  of  cases  (Macewen)  lies  in  whole  or  in  part  within  the 
suprameatal  triangle;  that  in  the  adult  its  depth  beneath  the  cortical  bone  varies 
from  one-eighth  to  three-fourths  of  an  inch. 

With  a  probe,  once  more  observe  the  direction  and  depth  of  the  bony  meatus. 
With  the  curette,  cautiously  remove  the  cancellous  bone  from  the  suprameatal 
triangle  in  a  direction  parallel  to  the  posterior  wall  of  the  bony  meatus.  This 
will  almost  inevitably  open  the  antrum.  If  the  bone  is  much  sclerosed,  a  small 
gouge  must  be  used  instead  of  the  curette.     Having  opened  the  antrum,  explore 


Fig.  26. — Left  Temporal  Bone. 
Antrum  and  most  of  the  mastoid  cells  obliterated,     i.  Semicircular  canals.     2.  Loca- 
tion of  facial  nerve  in  aqueduct  of  Fallopius,  which  has  been  opened.     3.  Location  of 
sigmoid  sinus. 


it  thoroughly  with  a  probe.  With  the  curette,  aided,  if  necessary,  by  rongeur 
forceps,  remove  all  the  external  wall  of  the  antrum.  In  the  same  manner 
remove  all  the  mastoid  air-spaces.  Every  step  in  the  removal  of  bone  must  be 
preceded  by  careful  examination  of  the  tissues  to  be  removed;  remember  par- 
ticularly the  normal  site  of  the  facial  nerve  (Fig.  26)  and  the  normal,  and  par- 
ticularly the  abnormal,  course  of  the  sigmoid  sinus. 

The  mastoid  has  now  been  converted  into  a  comparatively  shallow  pit. 
Examine  the  walls  of  the  pit  carefully  to  see  whether  the  disease  process  does  or 
does  not  penetrate  the  cranial  cavity.  If  the  disease  involves  the  sigmoid  sinus 
or  the  meninges  elsewhere,  it  must  be  attacked  according  to  the  principles 
already  enunciated. 


meningocelp:.  37 

In  acute  mastoiditis,  after  the  antrum,  etc.,  have  been  cleaned  out,  the  inflam- 
mation of  the  tympanum  will  promptly  recede;  hence  it  is  unnecessary  to  use 
the  curette  in  the  tympanic  cavity  (Whiting).  This  is  fortunate,  as  otherwise 
much  damage  to  hearing  might  easily  be  intlicted.  In  cases  of  chronic  mastoid- 
itis and  otitis  the  tympanum  must  be  thoroughly  opened  and  appropriately 
treated  along  the  lines  laid  down  on  page  3 1  et  seq. 

Step  5. — With  rongeur  forceps  and  curette  make  smooth  the  floor  and  sides 
of  the  bony  defect.  Partially  close  the  wound  in  the  soft  parts  with  sutures. 
Pack  the  remainder  of  the  wound  with  iodoform  gauze.  It  is  comforting  to  the 
patient  to  have  the  gauze  separated  from  the  wound  by  a  layer  of  perforated 
oiled  sUk  or  rubber  tissue.  After  granulations  have  formed  along  the  course  of 
the  pack  they  may  be  covered  by  Thiersch's  skin-grafts.  This  is  usually  two 
or  three  weeks  after  the  operation. 

It  must  be  remembered  that  in  children  under  three  years  of  age  the  mastoid 
process  is  either  absent,  or  its  presence  is  merely  indicated,  while  the  antrum  is  to 
be  sought  rather  higher  than  in  the  adult.  In  these  young  children  the  bone  is 
so  soft  that  the  antrum  may  be  opened  with  a  curette. 

In  cases  of  acute  (not  chronic)  mastoiditis  Stenger  makes  a  short  incision 
over  the  mastoid,  reflects  the  periosteum  and  if  no  fistula  is  present,  chisels  or 
bores  a  narrow  passage  towards  the  antrum.  He  curettes  this  passage  (which 
need  not  penetrate  the  antrum)  or  the  fistula,  if  such  is  present  and  loosely  packs 
with  gauze;  dries  the  surrounding  skin  and  applies  a  cupping  glass  provided 
with  some  form  of  pump  for  suction.  A  sterile  ointment  spread  on  the  skin 
makes  the  cupping  glass  act  better.  The  suction  is  kept  up  not  longer  than  three 
hours  at  a  time.  The  suction  causes  pain  while  it  acts  but  the  relief  is  great 
during  the  intervals.  Stenger  and  Hasslauer  report  excellent  results  and  a 
shortening  of  convalescence.     ("  Muenchner  med.  Wochensch.,"  Aug.  21,  1906.) 

The  use  of  suction  by  means  of  the  cup  undoubtedly  may  help  drainage 
but  its  main  object  is  to  obtain  hyperemia  and  the  whole  procedure  is  based  on 
the  ideas  of  Bier. 

OPERATIVE   TREATMENT    OF   MENINGOCELE  AND 
ENCEPHALOCELE. 

Operation  should  not  be  undertaken  in  cases  of  the  above  tumors  when  there 
are  serious  concomitant  malformations  or  when  it  is  believed  that  portions  of 
brain,  necessary  to  life,  are  present  in  the  growth.  Horsley  has  suggested  the  ap- 
plication of  the  induced  current  to  the  tumor  in  order  to  diagnose  if  important 
cerebral  tissue  is  involved.  Some  surgeons — e.  g.,  Berger — believe,  and  act 
on  the  belief,  that  any  cerebral  material  present  in  a  meningocele  is  neoplastic  in 
nature  and  possesses  no  physiological  function  and  may  safely  be  disregarded. 
With  the  exceptions  mentioned  above  Chipault  considers  all  cases  of  meningo- 
cele suitable  for  operation.  [Meningoceles  of  the  cranial  vault  are  alone  refer- 
red to  at  present.] 


38  THE    SKULL  AND    THE    BRAIN. 

The  Operation.— Trace  out  two  flaps  of  skin  alone,  over  the  tumor.  The 
base  of  each  flap  corresponds  to  the  pedicle  of  the  tumor.  Reflect  the  flaps. 
Expose  the  pedicle  of  the  tumor  at  its  exit  from  the  skull.  Transfix  the  pedicle, 
with  a  blunt  needle,  close  to  the  skull,  in  one  or  more  places,  and  apply  two  or 
more  interlocked  catgut  ligatures.  Tie  the  ligatures.  Cut  away  the  tumor 
distal  to  the  ligatures.  Replace  the  skin-flaps.  Suture.  Dress.  Instead  of 
ligating  the  pedicle  as  above  described,  it  is  better  to  open  and  explore  the  sac. 
If  brain  tissue  is  present,  looks  normal  in  character,  and  is  reducible  without 
giving  rise  to  symptoms  of  compression,  reduce  such  brain  tissue,  excise  the 
rest  of  the  tumor,  and  close  the  opening  in  the  cerebral  membranes  with  suture. 
If  no  brain  tissue  is  present,  excise  the  sac.  If  brain  tissue  is  present  but  is 
either  abnormal  in  appearance  or  irreducible,  it  must  be  excised.  From  the 
literature  of  nine  years  Chipault  collected  fifty  cases  of  meningocele  subjected 
to  operation  with  only  nine  deaths. 

Meningoceles  protruding  through  the  base  of  the  skull  are  rarely  in  situa- 
tions accessible  to  the  surgeon.  In  one  case  Fenger  gained  access  to  the  tumor 
by  temporarily  resecting  the  superior  maxilla,  and  saved  his  patient.  When  it  is 
possible  to  expose  a  basal  meningocele  the  principles  of  operation  are  the  same 
as  those  already  described. 

MICROCEPHALUS.     IDIOCY. 

Lane,  Fuller,  and  Lannelongue  advised  removal  of  portions  of  the  skull  in 
cases  of  microcephalus,  on  the  supposition  that  the  early  closure  of  the  skull  and 
consequent  defective  bone  cavity  impeded  cerebral  development.  Variously 
shaped  portions  or  strips  of  skull  have  been  removed  by  many  surgeons  and  the 
primary  results  seemed  promising.  The  author  in  several  cases  was  astounded 
to  find,  even  on  the  day  following  operation,  marked  improvement  in  the 
condition  of  such  patients.  The  improvements  in  speech  and  mentality  were 
truly  incredible,  but  in  not  one  of  the  cases  observed  by  him  were  these  improve- 
ments retained,  and  he  is  forced  to  conclude  that  such  operations  are  worthless. 
They  will  not  be  described  here. 

HYDROCEPHALUS. 

The  earliest  attempts  to  treat  hydrocephalus  by  surgical  means  consisted 
in  the  application  of  strapping  to  the  head  in  the  endeavor  to  prevent  its 
increase  in  size  or  to  diminish  its  size.  Such  means  were  doomed  to  failure. 
Later,  paracentesis  was  resorted  to,  and  cerebrospinal  fluid  was  removed  in 
greater  or  less  quantity,  but  though  repeated  paracentesis  occasionally  gave 
relief  yet  sooner  or  later  meningitis  generally  developed   and   death  ensued. 

Mikulicz  suggested  draining  the  cerebrospinal  fluid  into  the  tissues  under  the 
scalp  and  this  procedure  was  carried  out  in  several  different  ways.  Metal  tubes 
were  inserted  so  as  to  conduct  fluids  from  the  ventricles  to  the  subcutaneous 
tissues.     Silk  threads,  formalinized  arteries  or  veins  were  used  for  the  same 


HYDROCEPHALUS. 


39 


purpose  but,  as  is  noted  elsewhere,  while  temporary  success  was  not  infrequent, 
the  subcutaneous  tissues  refused  to  continue  acting  as  absorbents  and  per- 
manent good  results  were  notable  because  of  their  absence. 

Leonard  Hill  (quoted  by  Cheyne  and  Burghard)  has  shown  that  the  amount 
of  cerebrospinal  fluid  is  regulated  by  absorption  and  exudation  from  the  veins  or 
lymphatics  of  the  brain,  more  especially  towards  the  base;  and  if  any  cause 
interferes  with  the  normal  regulation  of  this  cerebrospinal  fluid  the  result  on 
the  brain  will  be  very  serious.  Meningitis  interferes  with  this  regulation,  so  that 
the  fluid  collects  in  the  ventricles  and  causes  hydrocephalus.  The  meningitis  at 
fault  is  specially  present  at  the  base  of  the  brain  near  the  fourth  ventricle, 
obstructing  the  exit  of  fluid  from  the  ventricles,  and  hence  its  proper  absorp- 
tion. Based  on  the  above,  G.  A.  Sutherland  and  one  of  the  authors  referred  to, 
attempted  to  establish  the  natural  absorption  by  the  following  operation: 


Fig.  27. 


Reflect  a  flap  of  scalp  and  open  the  skull  near  and  posterior  to  the  anterior 
fontanelle  (occasionally  the  lower  angle  of  the  fontanelle  itself  has  been  opened). 
Incise  the  dura.  Take  about  twelve  strands  of  thin  catgut  2  to  3  inches  in 
length  and  tie  the  ends  together.  Pass  one  end  of  this  bunch  of  catgut  down- 
wards and  backwards  between  the  brain  and  the  dura  until  ahout  3/4  inch  is  left 
projecting  from  the  opening  in  the  dura.  Seize  the  free  end  of  this  projecting 
portion  in  a  forceps  and  push  it  through  the  brain  into  the  lateral  ventricle. 
Thus  a  catgut  drain  is  made  to  stretch  from  the  ventricle  into  the  subdural  space. 
Close  the  wound  in  the  dura  and  the  scalp.  As  a  rule,  the  temperature  runs  up 
to  104°  or  105°  F.,  but  falls  again  in  the  course  of  a  week  or  ten  days.  The  skull 
soon  diminishes  in  size  to  a  very  marked  degree. 

The  results  have  been  better  in  congenital  than  in  acquired  hydrocephalus; 
in  the  latter  it  has  been  extremely  difficult  to  keep  up  a  channel  of  communica- 
tion between  the  ventricles  and  the  subdural  space,  and  it  has  been  suggested 
to  use  a  more  resistant  form  of  drain.  In  spite  of  the  success  attained,  the 
patients  have  generally  succumbed,  after  a  few  months,  to  progressive 
meningitis. 

Ballance  ("Am.  Surg.  Assoc,"  1906)  finds  the  thread  drainage  insufficient, 


40  THE  SKULL  AND  THE  BRAIN. 

therefore  he  uses  a  fine  f~  -shaped  tube  of  pure  platinum  or  of  gold  and  iridium 
(pure  gold  is  too  soft).  One  limb  of  the  tube  is  provided  with  a  small  ring  or 
loop  near  the  angle.  One  leg  of  the  tube  is  made  to  penetrate  the  ventricle, 
the  other  leg  lies  between  the  brain  and  the  dura,  being  fixed  to  the  latter  by 
sutures  (Fig.  27). 

Ballance  has  had  a  number  of  complete  recoveries  from  hydrocephalus 
following  ligation  of  both  common  carotid  arteries  at  an  interval  of  about  ten 
days.  In  these  cases  there  is  no  special  danger  from  shutting  oflf  both  common 
carotids. 

V.  Bramann  endeavors  to  attain  the  same  end  by  means  of  puncture  of 
the  corpus  callosum  (see  p.  28). 

The  blood  pressure  in  the  cerebral  sinuses  being  very  low  Payr  conceived 
the  idea  that  it  would  be  possible  to  drain  cerebrospinal  fluid  directly  into  the 
longitudinal  sinus.  As  an  aqueduct  from  the  lateral  ventricle  to  the  sinus  a 
tube  lined  with  endothelium  and  provided  with  valves  to  prevent  reflux  of  blood 
is  desirable.  Such  a  vein  as  the  great  saphenous,  if  transplanted,  is  calculated 
to  fulfill  the  requirements. 

Payr's  Operation  ("Archiv  fur  klin.  Chir.,"  Ixxxvii,  Hft.  4). 

I.  Make  a  transverse  U-shaped  flap  consisting  of  skin  periosteum  and  bone 
as  shown  in  Fig.  28.     The  convexity  of  the  flap  is  on  the  side  to  be  drained  and 

its  pedicle,  2  to  3  cm.  wide,  is  at  least  one  finger's 
breadth  to  the  opposite  side  of  the  mid-line. 
Reflect  the  flap. 

2.  On  each  side  of  the  longitudinal  sinus 
elevate  a  U-shaped  flap  of  dura  having  its  base 
toward  the  sinus. 

3.  With  an  exploring  needle  of  small  size  and 
having  a  scale  marked  in  1/2  cms.  on  it,  puncture 
the  lateral  ventricle  at  a  spot  not  far  from  the 
longitudinal  fissure  and  drain  oflf  slowly  a  small 
quantity  of  fluid  and  at  the  same  time  note  the 
depth  of  the  ventricle  from  the  surface.  Remove 
the  exploring  needle — it  has  served  its  purpose  of 

Fig.  28. — {Payr.)  relieving  tension  and  showing  the  distance  of  the 

ventricle  from  the  surface. 

4.  Have  an  assistant  make  a  long  incision  over  the  long  saphenous  vein  and 
by  sharp  dissection  remove  a  segment  of  it.  There  must  be  no  bruising  of  the 
vein.  The  length  of  the  vein  requisite  must  be  from  50  per  cent,  to  60  per  cent, 
longer  than  the  distance  from  the  longitudinal  sinus  to  the  ventricle  as  the  excised 
vein  shrinks  very  markedly.  When  excised  place  the  vein  on  gauze  soaked  in 
warm  salt  solution  and  keep  it  warm.  Note  and  remember  which  is  the  proxi- 
mal end  of  the  vein  as  that  is  the  end  which  must  be  sutured  to  the  sinus  in  order 
to  take  advantage  of  the  valves  in  the  vein. 

5.  Penetrate  the  ventricle  with  an  aluminum  trocar  (2  to  3  to  4  mm.  in 


HYDROCEPHALUS.  4 1 

diameter)  which  has  a  1/2  cm.  scale  marked  on  it.     Permit  the  fluid  to  escape 
very  slowly;  a  plug  of  cotton  in  the  trocar  permits  the  fluid  to  escape  in  drops. 

6.  At  least  2  to  3  cm.  of  the  longitudinal  sinus  is  exposed.  Lift  up  the  two 
dural  flaps  made  in  Step  2.  This  permits  one  to  see  the  falx  under  the  sinus. 
With  semiblunt  needles  threaded  with  thin  elastic  or  with  a  thin  rubber  tube 
perforate  the  falx  anteriorly  and  posteriorly  to  the  exposed  segment  of  sinus.  In 
this  manner  an  elastic  band  goes  from  side  to  side  under  the  sinus — one  in  front 
and  one  behind  the  site  of  proposed  anastomosis — and  when  fixed  by  a  stitch 
to  the  scalp  on  each  side  of  the  sinus  these  exercise  pressure  on  the  sinus  and 
so  stop  the  circulation  temporarily. 

7.  To  the  right  and  to  the  left  of  the  site  chosen  for  anastomosis  intro- 
duce and  tie  a  suture  of  fine  silk  which  penetrates  only  the  external  tunics  of  the 
sinus.  Leave  the  ends  of  these  sutures  long.  If  bleeding  takes  place  when  the 
sinus  is  incised  it  can  be  promptly  stopped  by  crossing  the  sutures. 

8.  Incise  the  sinus  and  introduce  into  it  obliquely  and  backwards  the 
proximal  end  of  the  excised  long  saphenous  vein.  It  is  wise  to  have  the  end  of 
the  vein  folded  back  like  a  cuff  so  that  any  part  of  it  which  may  protrude  into 
the  sinus  is  covered  with  endothelium.  With  fine  silk  sutures  fix  the  vein  to 
the  opening  in  the  sinus  and  as  supporting  sutures  tie  together  gently  the  two 
threads  introduced  in  Step   7. 

9.  Remove  the  aluminum  trocar  from  the  ventricle  and  push  the  free  end  of 
the  segment  of  vein  along  its  course  into  the  ventricle.  This  may  be  done  with  a 
stniette  of  stiff  silver  wire.  It  is  well  to  have  the  end  of  the  vein  turned  back  on 
itself  in  cuff  fashion. 

10.  Remove  the  elastic  constrictors  from  the  sinus.  Close  the  dural  wound. 
Close  the  cranial-scalp  wound. 

Several  observers  have  noted  that  when  drainage  has  been  established 
between  the  ventricles  or  the  meninges  and  the  cellular  tissues,  absorption  of 
the  fluid  was  at  first  satisfactory  but  that  later  the  cellular  tissues  refused  to  con- 
tinue absorbing  the  fluid  and  encysted  it  instead.  A.  H.  Ferguson  drilled  a 
hole  through  the  body  of  the  fifth  lumbar  vertebra  and  passed  a  silver  wire 
through  it  from  the  spinal  to  the  peritoneal  cavity.  Nicoll  proposed  the 
following  steps:  laminectomy;  resection  of  a  transverse  process;  insertion 
of  a  tube  (decalcified  bone,  glass)  from  the  spinal  meninges  to  the  perito- 
neum; instead  of  inserting  a  tube  Nicoll  has  sutured  a  tag  of  omentum  to  the 
meninges. 

HeUe  has  sutured  the  meninges  to  the  peritoneum  of  the  large  intestine. 
Harvey  Cushing  has  endeavored  to  establish  drainage  between  the  meninges 
and  the  neighborhood  of  the  peritoneum.  The  following  is  quoted  from 
Cushing's  article  in  Keen's  Surgery:  "It  is  essential  in  the  first  place  to  deter- 
mine if  possible  where  the  obstruction  lies,  for  if  it  is  evident  that  the  foramina  of 
Magendie  and  Luschka  are  occluded,  some  method  of  direct  ventricular  drain- 
age must  be  resorted  to.  As  ihejirst  step  a  lumbar  puncture  is  performed,  the 
tension  of  the  fluid  is  registered,  and  if  an  amount  sufficient  to  demonstrate  that 


42  THE    SKULL  AND    THE    BRAIN. 

it  must  come  from  the  ventricle  can  be  withdrawn,  the  needle  is  removed  and 
the  fluid  analyzed. 

The  second  step,  carried  out  some  days  later,  is  to  determine  whether  the  child 
will  withstand  the  withdrawal  of  a  large  amount  of  fluid,  for  though  I  have  never 
seen  convulsions,  collapse,  etc.,  from  this  source,  such  accidents  have  been 
recorded  by  Keen  and  others.  To  do  this,  a  combined  puncture  of  the  lumbar 
region  and  ventricle. is  performed.  A  long  glass  tube  of  small  calibre  connects, 
by  a  short  rubber  tube,  with  each  needle,  and  the.  fluid,  when  lumbar  or  ven- 
tricular space  has  been  entered,  spurts  up  into  the  tube  to  its  tension  level,  about 
which  it  fluctuates  with  the  cardiac  and  respiratory  rhythm.  If  the  foramen  of 
Magendie  is  open  the  fluid  seeks  the  same  level  in  both  tubes,  and  when  either  of 
them  is  dropped  and  the  fluid  allowed  to  escape  the  level  in  the  other  falls. 
Thus,  the  ventricle  may  be  emptied  by  either  tube — rapidly  by  the  ventricular, 
slowly  by  the  lumbar — and  I  have  withdrawn  in  this  way  from  the  lumbar 
subarachnoid  space  alone  as  much  as  a  litre  of  fluid.  The  tubes  are  then  with- 
drawn, the  small  scalp  wound  closed,  dressed,  and  the  fluid  allowed  to  reaccu- 
mulate.  A  comparative  chemical  analysis  of  the  fluid  taken  from  the  two 
sources  should  show  them  to  be  the  same.  When  thus  demonstrated  that  the 
ventricular  fluid  already  communicates  by  natural  channels  with  the  subarach- 
noid space,  it  becomes  evident  that  an  additional  operative  communication 
between  ventricle  and  the  subarachnoid  spaces  over  the  hemisphere  is  super- 
fluous and  unavailing.  The  indication  is  clear  that  one  must  find  some  other 
means  of  escape  for  the  fluid,  and  I  have  attempted  to  drain  into  the  retroper- 
itoneal space  as  follows: 

Third  Step. — It  having  become  established  i.  that  the  ventricle  can  be  emp- 
tied by  the  lumbar  route  and  2.  that  the  withdrawal  of  fluid  is  not  prejudicial 
to  the  child's  well-being,  the  following  procedure,  after  an  interval  of  some  days, 
is  carried  out.  A  laparotomy  is  performed;  the  posterior  layer  of  peritoneum  to 
the  left  of  the  rectum  is  split;  the  body  of  the  fifth  lumbar  vertebra  just  under 
the  bifurcation  of  the  vessels  is  exposed;  the  bone  is  trephined  by  a  specially 
constructed  small-calibre  trephine,  and  one-half  (the  female  portion)  of  a  silver 
cannula,  exactly  the  size  of  the  trephine,  is  inserted  and  held  in  position.  The 
child  is  then  turned  on  its  face  and  a  laminectomy  is  performed;  the  subarach- 
noid space  is  opened,  the  strands  of  the  cauda  separated,  and  the  posterior  half 
(male  portion)  of  the  cannula  is  invaginated,  so  that  it  locks  into  the  portion 
inserted  anteriorly.  Both  wounds  are  then  closed.  The  fluid  for  a  time  finds 
its  way  into  the  peritoneal  cavity,  but  ultimately  only  into  the  retroperitoneal 
space,  whence  it  is  taken  up  by  the  receptaculum  chyli,  as  experimental  obser- 
vations have  shown.  It  can  be  seen  that  this  combined  lumbar  method  is 
especially  desirable  in  cases  of  hydrocephalus  complicated  by  spina  bifida,  a 
radical  cure  of  which  may  be  made  in  association  with  the  posterior  part  of  the 
operation.  I  have  carried  out  this  procedure,  which  is  briefly  recorded  here 
for  the  first  time,  in  twelve  cases,  with  a  considerable  measure  of  success." 


ACUTE    HYDROCEPHALUS. 


43 


ACUTE  HYDROCEPHALUS,  DRAINAGE  OF  LATERAL  VENTRICLE. 

Keen's  Method.— (A)  Choose  a  point  i  1/4  inches  above  the  upper  margin 
of  the  external  auditory  meatus  and  the  same  distance  behind  the  meatus. 
Open  the  skull  at  this  point  with  a  1/2  inch  trephine.  On  the  opposite  side  of 
the  head  choose  the  point  H  (Fig.  29)  2  1/2  to  3  inches  above  the  meatus  audi- 
torius.  Through  the  trephine  opening  pass  a  grooved  director  or  fine  cannula 
towards  the  point  H.  The  cannula  should  reach  the  ventricle  at  a  depth  of  2  to 
21/4  inches.  If  drainage  is  required  introduce  some  threads  of  horse-hair  or  a 
fine  tube  of  rubber. 


Fig.  29. — Puncture  of  the  Lateral  Ventricle  by  the  Lateral  Route  at  A. — [Keen.) 

{Am.  Text-hook  of  Surg.) 


OPERATIONS  IN  CASE  OF  EPILEPSY. 

L  Idiopathic  Epilepsy. — (A)  Prophylactic  Treatment. — The  report  of 
results  obtained  in  Korte's  clinic  (see  p.  15)  in  cases  of  complicated  fractures  of 
the  skull  very  strongly  indicates  the  propriety  of  restoring  the  integrity  of  the 
skull  after  operations  or  fractures.  The  methods  of  doing  this  are  discussed 
elsewhere  (see  p.  11). 

Prophylatic  treatment  resolves  itself  essentially  into  the  avoidance  of  local 
irritation  and  the  obtaining  the  most  complete  repair  feasible. 

(B)  Operative  Treatment. — The  name  idiopathic  epilepsy  is  used  as  a  cloak 
for  ignorance  and  to  denominate  the  non-focal  forms  of  the  disease.  Many 
operations  have  been  performed  for  the  cure  of  the  disease;  the  results  have 
been  good,  bad  and  nil;  negative  results  being  the  rule.     The  fact  that  many 


44  THE    SKULL  AND    THE    BRAIN. 

operations  on  regions  apparently  unconnected  directly  with  the  head  have  been 
followed  by  symtomatic  cure  of  the  disease  led  J.  W.  White  to  speak  of  "opera- 
tions per  5e"  being  occasionally  curative.  Undoubtedly  it  is  good  practice  to 
correct  possible  sources  of  irritation  in  epileptics,  such  as  eye-strain,  tight  fore- 
skin, decayed  teeth,  etc. 

After  shaving  the  head,  scars  will  commonly  be  found  on  the  scalp,  even 
when  no  history  of  trauma  has  been  elicited.  Many  of  these  scars  are  undoubt- 
edly the  result  of  accidents  directly  due  to  the  epilepsy,  but  as  undoubtedly,  in 
occasional  cases,  one  of  the  scars  is  the  visible  evidence  of  a  trauma  which  oc- 
casioned the  epilepsy.  All  such  scars  should  be  carefully  examined  as  regards 
{a)  tenderness  to  touch  or  to  percussion,  {h)  mobility  or  adhesion,  (c)  condi- 
tion of  periosteum  or  bone,  (d)  the  production  of  vasomotor  or  psychic  symp- 
toms on  manipulation. 

Keen  is  so  strongly  convinced  that  a  scar  of  the  scalp  may  be  the  cause  of 
epilepsy  that  after  having  excised  the  scar  and  having  found  the  bone  without 
evidence  of  injury,  he  closes  the  wound  and  waits;  if  excising  the  scar  fails  to 
cure,  he  then — and  not  until  then — considers  the  advisability  of  performing 
some  other  operation. 

Friedrich,  in  traumatic  epilepsy,  chooses  the  site  of  trauma  as  the  site  for 
operation  even  when  the  "aura"  would  indicate  some  other  location  as  the  start- 
ing-point of  the  epileptic  explosion. 

Kocher,  believing  increased  intracranial  pressure  to  be  the  important 
etiologic  factor  in  idiopathic  epilepsy,  trephines  and  excises  the  dura  over  the 
right  fronto-parietal  reigon,  as  a  rule;  to  this  he  sometimes  adds  drainage  of  the 
lateral  ventricle. 

Friedrich's  results  ("Archiv  fur  khn.  Chir.,"  Ixxvii,  Hft.  3)  in  eight  cases 
kept  under  observation  for  years  after  operation  show  one  case  cured  of  epi- 
lepsy and  coincident  mental  disturbances;  two  cases  of  very  great  improve- 
ment; one  of  improvement;  one  of  temporary  improvement;  three  unimproved. 

If  not  guided  by  the  evidences  of  old  trauma  Friedrich  follows  Kocher  and 
operates  over  the  posterior  portion  of  the  frontal  lobes  (right). 

The  operation  is  as  follows: 

Step  I. — Reflect  a  large  flap  of  scalp,  having  its  pedicle  below.  Open  the 
skull  and  excise  with  forceps  or  other  instruments  a  segment  of  bone.  The  size 
of  the  segment  of  bone  removed  varies  from  20  to  48  sq.  cm.  (8  to  19  sq.  in.). 

Step  2. — ^Very  carefully  remove  an  area  of  dura  varying  in  size  from  9  to  33 
sq.  cm.  (3  1/2  to  13  sq.  in.).  Do  not  injure  the  subjacent  pia.  Avoid  as  far  as 
possible  all  hemorrhage. 

Step  3. — Replace  the  flap  of  scalp  and  suture.     Apply  dressings. 

C.  H.  Mayo  has  had  some  success  after  operating  as  follows:  Reflect  a  large 
osteoplastic  flap;  cut  the  fractured  edges  of  the  bone  smooth.  Reflect  a  flap  of 
dura  corresponding  to  the  osseous  defect.  Push  the  dural  flap  into  a  pocket 
between  the  scalp  and  the  bone  (Fig.  30).  Replace  the  osteoplastic  flap,  the 
bone  of  which  lies  next  to  the  pia  arachnoid.     The  dural  flap  acts  as  a  drain 


EPILEPSY. 


45 


between  the  meninges  and  subcutaneous  lymphatics.  Cushing's  decompressive 
operation  may  be  employed. 

Although  all  such  operations  are  perfectly  justifiable  under  proper  conditions, 
yet  the  surgeon  must  not  be  too  sanguine  as  to  results.  Almost  any  operation 
is  frequently  followed  by  a  temporary  cessation  of  epileptic  seizures,  but  re- 
currence is  the  almost  invariable  rule.  Jonnesco's  method  of  sympathectomy 
cannot  be  considered  of  proved  value. 

II.  Focal  or  Jacksonian  Epilepsy. — In  focal  epilepsy  the  irritation  seems 
to  originate  in  some  particular  point  on  the  surface  of  the  brain  and  to  radiate  to 
other  parts.  The  parts  affected  are  those  which  have  been  mapped  out  in  the 
study  of  cerebral  localization.  The  causes  of  this  condition  are  numerous. 
Depressed  fracture,  osteophytic  growths,  neoplasms,  localized  meningitis  caus- 
ing adhesions,  hemorrhage,  abscess,  etc.,  are  all  efficient  causes  and  ought  to  be 


Fig.  30. 

removed  or  corrected.  If  no  macroscopic  lesion  can  be  found  when  the  skull  is 
opened  and  the  brain  exposed,  the  precise  area  from  which  the  attacks  radiate 
may  be  defined  by  means  of  stimulation  by  weak  electrical  currents.  The  gray 
matter  of  this  area,  plus  the  pia  mater  covering  it,  may  be  excised.  Of  course, 
excision  of  an  area  of  cortex  means  paralysis  of  the  regions  controlled  by  this 
area,  but  the  paralysis  seldom  remains  permanent.  Immediately  after  the 
operation  there  is  often  a  very  temporary  paralysis  of  parts  supplied  by  neigh- 
boring centres.  A  few  good  results  have  followed  cortical  excision,  but  the  rule 
is  that  epilepsy  recurs  when  healing  takes  places.  If  a  scar  is  removed  from  the 
brain,  another  scar  is  necessarily  formed  in  the  process  of  repair.  There  is  a 
great  difference,  however,  between  the  scar  resulting  from  a  clean  incision  or 
excision  and  one  resulting  from  a  coarse  trauma  or  from  inflammation.  Cover- 
ing a  cerebral  wound  with  celluloid,  goldfoil,  or  rubber  tissue  prevents  adhesion 
between  the  brain,  meninges,  and  scalp  or  skull,  and  is  a  useful  precaution. 

Carl  Beck's  Operation. — In  some  cases  of  epilepsy  ("Annals  of  Surg.," 
Aug.,  1906)  due  to  adhesions  at  the  site  of  a  hiatus  in  the  skull,  the  result  of 


46 


THE    SKULL  AND    THE    BRAIN. 


fracture  or  operation,  Beck  has  obtained  some  good  results  by  plugging  the  skull 
defect  with  temporal  muscle  and  fascia,  the  fascia  being  placed  next  the  brain 
or  dura. 

The  Operation:  Step  i. — Make  the  n  incision  ABC  (Fig.  31)  and  reflect  the 
flap  of  scalp  thus  formed.  This  exposes  the  defect  in  skull.  Carefully  remove 
all  scar  tissue  and  exostoses  from  the  defect  and  its  surroundings.  This  means 
usually  removal  of  dura.  With  chisel  or  rongeur  remove  enough  bone  from 
around  the  defect  so  that  an  edge  of  intact  healthy  dura  is  exposed.  Attend  to 
hemostasis. 

Step  2. — Continue  the  incision  BA  to  D  and  BC  to  E,  and  reflect  the  flap 
DFE.  This  flap  must  consist  of  scalp  alone;  the  temporal  fascia  must  be  left 
intact. 


Step  3. — Form  the  flap  HKI  consisting  of  temporal  fascia,  temporal  muscle 
and  pericranium,  and  having  its  pedicle  towards  the  skull  defect.  This  flap 
must  be  large  enough  to  completely  fill  the  defect.  Turn  the  flap  HKI  upwards 
and  place  it  in  the  skull  defect,  the  temporal  fascia  lying  on  the  brain.  Suture 
the  temporal  fascia  to  the  dura. 

Step  4. — Attend  to  hemostasis.  Replace  the  flap  DEF  and  fix  it  with  sutures, 
providing  for  drainage,  if  necessary.     Apply  dressings. 

In  cases  similar  to  those  for  which  Beck  devised  his  operation  other  sur- 
geons reflect  the  scalp,  remove  scar  tissue,  etc.,  at  the  same  time  excising  scars 
in  the  dura  and  freshening  the  edges  of  the  bony  hiatus.  The  usual  methods 
of  endeavoring  to  prevent  fresh  dural  adhesions  have  been  described  else- 
where. Finsterer  replaced  destroyed  dura  vnth  a  portion  of  a  hernial  sac 
placed  with  its  serous  surface  towards  the  brain.  The  sac,  obtained  during  an 
operation  for  hernia,  had  been  preserved  in  a  2  per  cent,  formol  solution  but 
was  thoroughly  washed  in  normal  salt  solution  before  use  ("Beitrage  z.  klin. 


HYPOPHYSECTOMY.  47 

Chir.,"  Ixvii,  193).  In  experiments  made  on  dogs  Finsterer  found  that  such 
peritoneal  grafts  preserved  their  vitaHty  ( ?)  and  did  not  contract  adhesions  to  the 
subjacent  brain. 

Hanel  ("Archiv  fur  kUn.  Chir.,  xc,  823),  stimulated  by  Morris'  recommen- 
dation of  Cargile's  membrane,  prepared  material  from  the  intestines  of  sheep  as 
follows:  Bend  a  glass  rod  so  as  to  make  a  four-sided  frame;  split  open  and 
stretch  on  the  frame  a  segment  of  sheep's  intestine.  Soak  in  a  4  per  cent,  so- 
lution of  formalin  for  twelve  hours;  wash  in  running  water  twelve  hours;  boil  in 
water  for  ten  minutes;  preserve  in  the  following  solution:  sublimate  0.8,  gly- 
cerine 40.0,  alcohol  800.0.  Hanel  used  this  material  in  the  same  manner  as 
Finsterer  uses  hernial  sac  and  Morris  uses  Cargile  membrane.  Hand's  mem- 
brane is  absorbed  after  the  lapse  of  about  two  or  three  weeks. 

Kirschner  ("Archiv  flir  klin.  Chir.,"  xcii,  894)  recommends  the  use  of 
fascia  in  covering  dural  defects.  He  obtains  the  material  by  excising  a  suffi- 
ciency of  the  fascia  lata  from  the  patient  himself  and  after  cutting  away  all 
fat  from  it  places  it  over  the  dural  defect  and  pushes  its  edges  under  the  skull 
between  the  dura  and  the  bone. 

HEMORRHAGIC  PACHYMENINGITIS. 

Bullard  and  John  C.  Munro  have  made  strong  pleas  for  the  consideration 
of  hemorrhagic  pachymeningitis  as  a  surgical  condition  demanding  operation. 
The  disease,  when  not  found  in  infants  or  the  insane,  is  one  belonging  to  the 
later  years  of  life.  Alcoholism,  syphilis,  acute  and  wasting  diseases,  as  well  as 
trauma,  seem  to  have  some  causal  relation  to  the  disease.  The  symptoms  are 
those  of  diffuse  subdural  hemorrhage,  coming  on  slowly,  producing  mental 
irritation,  spasm,  paralysis,  the  sequences  being  more  or  less  irregular.  The 
cranial  nerves  are  not  liable  to  be  affected.  Without  relief  by  operation  the 
prognosis  is  practically  hopeless;  with  operation,  it  is  still  very  poor  but  better 
than  without.  One  of  Munro's  cases  recovered;  it  was  that  of  an  alcoholic 
sixty-two  years  of  age,  picked  up  on  the  streets  unconscious.  On  admission  to 
hospital  he  could  not  be  roused.  There  was  no  bleeding  from  the  mouth,  nose, 
or  ears.  Temperature  was  normal,  pulse  80;  right  knee-jerk  absent;  no  rigidity; 
hematoma  in  right  parietal  region.  Trephined  on  right  side;  no  pulsation  of 
dura,  which  was  bulging  and  dark  blue.  Subdural  clot  covering  the  whole 
hemisphere  removed.  Trephined  on  left  side;  a  diffuse,  thin  clot  was  found 
and  removed.  Towards  the  close  of  the  operation  consciousness  returned. 
The  result  was  complete  recovery.  In  another  case  failure  to  trephine  on  both 
sides  led  to  death,  though  immediate  improvement  followed  the  operation. 

HYPOPHYSECTOMY. 

Attempts  have  been  made  to  cure  or  relieve  patients  suffering  from  hyper- 
pituitarism (acromegaly)  and  hypopituitarism  by  excising  the  hypophysis 
(pituitary  body)  either  completely  or  incompletely.     The  pituitary  body  lying 


48 


THE   SKULL  AND   THE   BRAIN. 


as  it  does  in  the  sella  turcica  may  be  approached  from  above  and  the  side 
through  the  cranial  cavity  or  from  in  front  and  below. 

A.  Operation  from  Above. — Horsley  approaches  the  hypophysis  very 
much  as  one  does  the  Gasserian  ganglion.  On  the  right  side  he  makes  a  large 
opening  as  in  the  Hartley-Krause  operation,  then  lifts  up  the  temporo-sphenoidal 
lobe  with  broad  retractors  until  the  side  of  the  tumor  is  seen  lying  in  the  sella 
turcica.  The  tumor  when  exposed  is  incised  and  its  solid  contents  are  scraped 
away, 

L.  L.  McArthur  (Church,  "  Journ.  A.  M.  A.,"  July  19,  1909)  in  one  case 
made  a  semicircular  incision  from  the  external  orbital  process  to  a  point  above 


"'^^^ff^rff^ 


"'^^^frmfi^f^ 


Fig.  32. — (V.  Eiselsherg  Annals  Surgery.) 


P"iG.  33. — {v.  Eiselsherg  Annals  Surgery.) 


the  right  ear.  The  right  side  was  chosen  so  as  to  avoid  injuring  the  speech 
centres.  When  the  dura  was  opened  the  brain  was  found  to  be  normal  in 
appearance  but  friable.  The  frontal  lobe  was  raised  so  as  to  follow  the  wing  of 
the  sphenoid  to  the  sella  turcica.  This  step  was  very  difficult  and  caused  con- 
siderable laceration  of  the  brain,  A  cystic  tumor  of  the  hypophysis  was 
exposed,  evacuated  and  partly  removed.     The  patient  died. 

B.  Operation  from  in  Front  and  Below. — v.  Eiselsberg's  operation 
("Annals  Surg.,"  July,  1910). 

Step  I. — Make  an  incision  as  in  Fig.  32  down  to  the  bone. 


HYPOPHYSECTOMY. 


49 


Step  2. — Divide  the  nasal  bones  with  a  chisel,  the  cartilage  with  a  knife,  the 
septum  with  scissors,  and  so  reflect  the  whole  nose  to  the  right. 

Step  3. — Remove  the  turbinate  bones.  With  a  chisel  convert  the  anterior 
wall  of  the  frontal  sinus  into  a  flap  and  reflect  it  upwards  along  with  the  frontal 
flap  outlined  in  Fig.  33.     Remove  the  vomer  (Fig.  34). 


Fig.  34. — [y.  Eiselsberg  Annals  Surgery.) 

Step  4. — With  chisel  and  bone  forceps  remove  the  anterior  wall  of  the  sphe- 
noidal sinus  and  expose  the  prominence  of  the  hypophysis  lying  in  the  sella 
turcica. 

Step  5. — Keeping  strictly  in  the  middle  line  penetrate  the  bony  floor  of  the 
sella  which  forms  the  upper  posterior  wall  of  the  sphenoidal  sinus  (Fig.  35). 


v.. 

Fig.  35. — {v.  Eiselsberg  Annals  Surgery.) 

This  may  be  begun  with  a  chisel  and  completed  with  a  fine  bone  nipping  forceps 
or  a  punch. 

Step  6. — Incise  the  dura  covering  the  hypophysis.     Keep  in  the  middle  line 
to  avoid  injuring  the  optic  nerves  and  the  cavernous  sinuses. 
4 


50 


THE    SKULL  AND   THE   BRAIN. 


Step  7. — Remove  the  tumor  with  a  curette  or  evacuate  any  fluid  if  the  disease 
is  cystic. 

Step  8. — Pack  with  a  narrow  strip  of  iodoform  gauze. 

Step  9. — Replace  the  nose  and  the  anterior  wall  of  the  frontal  sinus.  Suture. 
V.  Eiselsberg  has  operated  six  times  on  the  hypophysis  and  tabulates  his  results 
as  follows:  First  group,  hypopituitism,  three  cases,  improved.  Second  group, 
acromegaly,  two  cases,  both  died.  Third  group,  mixed  type,  one  case,  im- 
proved. 

Kocher  in  operating  does  not  open  the  frontal  sinuses. 

Hochenegg's  Operation  (Stumme,  "Archiv  fiir  klin.  Chir.,"  Ixxxvii,  444). 

Step  I. — Place  a  plug  of  gauze  between  the  soft  palate  and  the  posterior  wall 
of  the  pharynx.  Hold  the  gauze  in  place  by  tapes  passed  through  the  nose  and 
mouth  and  tied  in  front  (Fig.  36). 


¥iG.  Tf6.— -{Slum me,  Archiv  fiir  Klin.  Chir.) 

Step  2. — Make  a  skin  incision  from  left  to  right  over  the  root  of  the  nose. 
On  the  right  side  continue  the  cut  downwards  along  the  side  of  the  nose  and 
around  the  right  nostril.  Through  this  incjsion  divide  the  cartilaginous  septum 
with  scissors,  the  bony  septum  with  forceps,  and  divide  the  nasal  bones  with  a 
chisel. 

Step  3. — From  the  original  skin  incision  make  two  other  cuts  following  the 
eyebrows  both  to  the  right  and  left.  Through  these  cuts  form,  with  a  chisel,  a 
skin-periosteum-bone  flap  containing  the  anterior  wall  of  the  frontal  sinus.  Re- 
flect the  flap  upwards. 

Step  4. — Turn  the  nose  to  the  left  and  remove  its  contents,  viz.,  septum,  tur- 
binate bones,  leaving  intact  the  inner  wall  of  the  orbit  and  the  wall  of  the  antrum 
of  Highmore.     Use  adrenalin  tampons  to  stop  bleeding. 

Step  5. — Open  the  sphenoid  sinus  and  proceed  as  in  v.  Eiselsberg's  operation. 
Kanavel  ("Journ.  A.  M.  A.,"  November  20,  1909)  devised  an  inf ranasal  route 
by  which  to  expose  the  hypophysis  and  yet  avoid  all  disfiguring  scars.     This 


HYPOPHYSECTOMY.  5 1 

operation  he  worked  out  on  the  cadaver,  but  it  was  first  used  on  the  hving  by 
A.  E.  Halstead  ("Surg.,  Gyn.,  Obstetrics,"  May,  1910)  who  associated  Kanavel 
with  him  in  the  operation.  Montgomery  West  ("  Journ.  A.  M.  A.,"  April  2, 
19 10)  has  devised  a  method  similar  to  Kanavel's  but  does  the  work  entirely 
through  the  nostril  without  dislocating  the  nose  Both  Kanavel  and  West 
suggest  that  it  may  be  well  to  operate  in  two  stages;  in  the  first  stage  clearing  the 
way  to  the  sella  turcica  (this  may  be  done  under  local  anesthesia),  in  the  second 
stage  removing  the  tumor. 

The  following  description  is  made  up  from  the  writings  of  Kanavel,  Halstead 
and  West  and  refers  to  operation  completed  in  one  stage. 

Anesthesia. — After  anesthesia  is  induced  in  the  usual  manner  Kanavel 
continues  the  administration  of  ether  by  the  rectal  method,  while  Halstead  per- 


FiG.  37. — {Kanavel  Jour.  A.  M.  A.) 

forms  tracheotomy  and  gives  chloroform  through  a  Trendelenburg  cannula.  To 
the  author  it  seems  that  lary^ngotomy  and  the  use  of  chloroform  through  Butlin's 
cannula  is  simpler  and  safer  than  tracheotomy.  The  advantage  of  anesthetizing 
through  a  tracheotomy  or  laryngotomy  cannula  over  the  rectal  method  consists 
in  the  ability  to  plug  the  pharynx  thoroughly  and  the  avoidance  of  all  respiratory 
troubles.  Before  giving  the  anesthetic  plug  the  nasal  passages  carefully  from 
the  anterior  nares  to  the  sphenoidal  cells  with  strips  of  gauze  soaked  in  adrenalin 
solution. 

The  Operation.  Step  i. — Tampon  the  pharynx.  Remove  the  adrenalin 
pack.  Raise  the  upper  lip.  Make  a  horizontal  incision  through  the  mucosa  of 
the  lip  about  5/6  inch  from  the  muco-cutaneous  junction  and  parallel  to  the 
alveolus.  Through  this  wound  dissect  upwards  freeing  the  nose  from  its  lateral 
attachments. 

Step  2. — With  strong  scissors  or  bone  forceps  divide  the  sep:um  along  its  in- 
ferior attachments  (line  b,  Fig.  37).     Divide  the  attachment  of  the  septum  to 


52  THE    SKULL  AND    THE    BRAIN. 

the  vertical  plate  of  the  ethmoid  (line  a,  Fig.  37).  Turn  the  nose  and  with  it 
the  separated  part  of  the  septum  upwards  on  to  the  forehead. 

Step  3. — Remove  the  lower  and  middle  turbinates,  the  vomer  and  the  per- 
pendicular plate  of  the  ethmoid.  The  anterior  wall  of  the  ethmoidal  sinus  is 
now  exposed. 

Step  4. — Penetrate  the  anterior  wall  of  the  sphenoidal  sinus.  Sometimes 
the  tumor  will  now  appear  having  eroding  the  sella  turcica.  If  this  has  not 
occurred,  open  the  sella  turcica  by  means  of  a  long  narrow  chisel.  While 
opening  the  sella  turcica  it  is  of  prime  importance  to  adhere  strictly  to  the 
middle  line  for  fear  of  damaging  the  carotid  arteries  and  the  optic  nerves. 

Step  5. — Treat  the  disease  by  evacuating  any  cyst  which  may  be  present  or 
gently  curetting  away  tumor  tissues. 

Step  6. — Pack  the  cavity  with  iodoform  gauze.  Replace  the  nose.  Suture 
the  septum.     Suture  the  wound  in  the  mouth. 

Results. — The  results  of  Kanavel's  operations  have  been  most  excellent  as 
regards  absence  of  deformity.  There  has  been  no  recognizable  deformity  in  any 
of  the  patients  submitted  to  operation. 

The  following  surgeons  have  operated  by  the  Kanavel  method  or  some 
modification  of  it: 

Halstead,  A.  E.  ("Surg.  Gyn.  Obst.,"  May  10),  two,  one  death.  Kanavel, 
two,  one  death.     Mixter,  S.  J.,  one,  no  death. 

In  Mixter's  case  and  in  Halstead's  successful  case  the  results  were  most 
gratifying.  Kanavel  (personal  communication)  writes:  "My  first  case  Hved 
about  five  weeks  and  then  died  from  a  recurrence.  After  the  operation  he 
had  been  up  and  left  the  hospital.  My  second  case  was  one  of  the  adipose 
genital  type,  and  has  remained  perfectly  well  ever  since  the  operation,  which 
relieved  him  of  all  the  symptoms  of  which  he  complained,  and  with  the  use  of 
the  anterior  lobe  of  the  pituitary  gland  he  is  now  beginning  to  grow." 

V.  Eiselsberg  has  operated  on  the  hypophysis  six  times;  in  only  two  of  his 
patients  was  there  acromegaly  and  in  both  of  these  death  resulted.  The  other 
operations  were  successful. 

Gushing,  Hochenegg,  Kocher  and  Smoler  have  each  operated  once  or 
oftener  by  various  methods  and  have  had  moderate  success. 

It  must  be  remembered  in  considering  statistics  that  the  operation  of  hy- 
pophysectomy  is  new  and  that  the  patients  who  have  submitted  to  the  operation 
were  usually  in  a  very  serious  condition,  i.  e.,  in  a  late  stage  of  disease. 

As  the  technic  of  the  operation  becomes  more  developed  and  knowledge  of 
the  disease  or  diseases  of  the  hypophysis  become  better  known,  undoubtedly 
cases  suitable  for  operation  will  be  seen  at  an  earlier  stage  of  the  disease  and  the 
results  of  surgical  treatment  will  become  very  much  better  than  at  present. 


CHAPTER  III. 
FRONTAL  SINUS. 

Operation  on  the  frontal  sinus  is  indicated  in  empyema  of  that  cavity. 
Frontal  empyema  is  usually  a  concomitant  of  some  form  of  chronic  rhinitis. 
Either  as  a  preliminar>'  or  complementary  step  in  the  operation  it  is  wise  to 
remove  the  anterior  portion  of  the  middle  turbinated  bone  in  order  to  simpHfy 
drainage. 

The  Operation. — Shave  the  eyebrow.  Clean  the  field  of  operation.  Pro- 
tect the  eyes  with  aseptic  pads. 

Step  I. — From  the  root  of  the  nose  make  a  curved  incision  outwards,  parallel 
to  and  i/8  inch  above  the  upper  margin  of  the  orbit.  The  incision  extends  to  a 
point  just  external  to  the  supraorbital  notch  and  penetrates  to  the  bone.  With 
the  periosteal  elevator  separate  the  soft  parts  from  the  bone  until  the  outer  wall 
of  the  sinus  is  exposed. 

Step  2. — With  a  bur,  small  trephine,  or  gouge  carefully  remove  the  exposed 
wall  of  the  sinus,  immediately  to  the  outer  side  of  the  middle  line,  above  the  root 
of  the  nose.  Only  a  very  small  area  of  bone  should  be  removed  at  this  time,  and 
care  is  necessary  lest  such  an  instrument  as  the  chisel  should  suddenly  pene- 
trate the  thin  bone  and  injure  the  posterior  or  inferior  walls  of  the  cavity.  As 
soon  as  the  bone  is  penetrated,  the  mucosa  lining  the  sinus  pouts  into  the 
wound.  Incise  the  mucosa.  Gently  explore  the  cavity  with  a  probe  and  with 
gouge  or  forceps  (guided  by  the  probe)  remove  the  anterior  wall  of  the  sinus. 
Some  surgeons  are  careful  not  to  remove  any  of  the  orbital  margin  lest  an  ugly 
deformity  result;  others  carefully  remove  every  particle  of  bone  which  might 
interfere  with  the  soft  parts  being  brought  in  absolute  contact  with  the  deep 
wall  of  the  sinus,  the  aim  being  to  obliterate  the  cav^ity.  Obliteration  of  the 
cavity  is  often  necessary,  but  as  it  causes  marked  deformity  one  is  wise  to  try 
less  mutilating  procedures  first. 

Step  3. — With  a  sharp  spoon  remove  all  granulation  tissue  from  the  sinus  and 
from  its  opening  into  the  nose.  With  a  small  sharp  spoon  cleanse  every  nook 
and  cranny.  Be  careful  not  to  injure  the  orbital  plate.  Pass  the  sharp  spoon 
from  the  postero-internal  angle  of  the  sinus  downwards  into  the  nose.  The 
instrument  goes  through  some  of  the  ethmoidal  cells  and  creates  a  good  passage 
for  drainage. 

Step  4. — Pass  a  rubber  tube  from  the  sinus  into  the  nose.  Some  surgeons  do 
not  permit  the  upper  end  of  the  tube  to  emerge  through  the  skin,  but  close  the 
cutaneous  wound  entirely,  trusting  to  nasal  drainage  alone,  as  ia  Earth's  opera- 
tion; most  operators  place  the  tube  so  that  it  emerges  both  through  the  skin  and 

53 


54 


FRONTAL   SINUS. 


the  nose.  Through-and-through  drainage  is  probably  best  to  begin  with. 
During  the  after-treatment,  if  it  becomes  necessary  to  withdraw  the  tube  tem- 
porarily, it  is  well  to  fasten  a  thread  to  the  tube,  so  that  as  the  tube  is  withdrawn 
the  thread  may  take  its  place  and  serve  as  a  guide  for  the  introduction  of  a  clean 
drain.     Close  all  excess  of  wound  with  sutures.     Dress. 

After-treatment. — Warn  the  patient  not  to  blow  his  nose  violently,  other- 
wise emphyijema  will  result.  When  nasal  drainage  alone  is  provided,  leave  the 
tube  in  situ  as  long  as  possible,  because  once  removed  it  is  very  difficult  to 
replace.  When  through-and-through  drainage  is  provided,  withdraw  the  drain 
gradually,  through  the  nose,  as  suppuration  lessens.  When  drainage  fails  to 
cure  the  disease,  the  sinus  must  be  obliterated  by  the  method  indicated  in 
Step  2. 

Killianh  operation  is  very  radical  and  successful.  (Freudenthal,  "Jour. 
Am.  Med.  Assoc,"  Feb.  ii,  1905.) 

Step  I. — Make  an  incision  down  to  the  bone  the  whole  length  of  the  eyebrow, 
just  above  the  orbital  margin.  Continue  the  incision  at  its  inner  end  down  the 
middle  of  the  nasal  process  of  the  superior  maxilla. 

Step  2. — Open  and  explore  the  sinus  either  above  or  below  the  orbital  margin. 
Step  7,. — With  chisel  and  mallet  make  a  furrow  through  the  bone  imme- 
diately above  and  parallel  to  the  margin  of  the 
orbit.  Remove  with  forceps  the  whole  anterior 
wall  of  the  frontal  sinus  above  the  furrow. 

Step  4. — Clean  out  the  sinus  and  remove  its 
mucous  membrane. 

Step  5. — Remove  with  forceps  the  whole 
(orbital)  floor  of  the  sinus,  leaving  the  orbital 
margin  intact  for  cosmetic  reasons. 

Step  6. — Resect  the  frontal  process  of  the 
superior  maxilla  and  the  rest  of  the  floor  of  the 
sinus. 

Step   7.- — Resect   the   anterior   and   middle 
ethmoidal  cells  and  the  respective  parts  of  the 
middle  turbinal.     These  structures  are  always  affected. 

Step  8. — Close  the  wound  after  providing  for  drainage  by  a  rubber  tube. 
The  extensive  removal  of  the  floor  of  the  sinus  and  consequent  opening  of  the 
orbit  cannot  be  without  danger.     The  inevitable  entrance  of  pyogenic  organisms 
into  the  non-resistant  fatty  tissues  must  often  give  rise  to  orbital  abscess. 

Earth's  Operation. — A  little  to  the  side  of  the  middle  line  at  the  root  of  the 
nose  make  a  longitudinal  incision  one  inch  in  length,  down  to  the  bone.  With 
a  chisel  carry  the  above  incision  through  the  nasal  porcess  of  the  frontal  bone 
and  the  nasal  bone.  At  the  upper  and  lower  angles  of  the  wound,  by  means  of  a 
narrow  chisel,  make  horizontal  cuts  outwards  through  the  bone.  The  flap  of 
bone  thus  formed  is  pried  outwards  (Fig.  38)  like  a  trap-door  with  hinge  placed 
externally.     The  upper  part  of  the  opening  is  filled  with  the  mucous  membrane 


Fig.  38. 


FRONTAL    SINUS.  55 

of  the  frontal  sinus.  Cut  through  this  bulging  mucous  membrane.  Through 
the  above  opening  diseased  tissue  may  be  inspected  and  removed,  free  drainage 
through  the  nose  may  be  provided,  and  if  necessar)'  the  opposite  sinus  may  be 
opened  and  treated.  When  the  operation  is  completed,  the  bone-flap  is  restored 
to  place  and  the  vertical  skin-incision  is  sutured. 


CHAPTER  IV. 
TIC  DOULOUREUX. 

In  severe  cases  of  trigeminal  neuralgia,  after  treatment  by  removal  of  sources 
of  peripheral  irritation  and  by  medicine  has  failed,  operation  offers  the  only 
hope  of  amelioration  or  cure.  Very  many  operations  have  been  devised,  but 
not  all  of  them  are  useful.  The  earliest  operations  consisted  in  the  subcuta- 
neous or  open  division  of  the  nerve-trunks  as  they  left  or  entered  their  bony  canals. 
The  supraorbital  nerve  was  divided  as  it  emerged  from  the  notch  of  the  same 
name,  the  infraorbital  at  the  infraorbital  foramen,  and  the  inferior  maxillary  as 
it  entered  the  posterior  dental  canal.  In  certain  cases  such  operations  gave 
marked  and  occasionally  permanent  relief,  but  after  simple  division  of  a  nerve 
repair  can  take  place  with  great  rapidity,  so  that  the  neuralgia  usually  recurs  at 
an  early  date. 

Thiersch,  after  exposing  the  nerves  at  their  exit  from  their  bony  canals,  seized 
them  in  strong  forceps  and  by  slow  twisting  and  pulling,  forcibly  extracted  a 
varying  amount  of  them  from  their  canal.  Recurrence  after  this  procedure  was 
neither  so  prompt  nor  so  constant  as  after  simple  division.  Undoubtedly  the 
best  method  of  operating  upon  the  nerve-trunks  is  by  the  removal  of  as  much  of 
them  as  is  possible,  or  by  injecting  into  them  materials  which  will  either  destroy 
or  diminish  their  power  of  conduction. 

INJECTIONS  INTO  THE  NERVES. 

Schlijsser  was  the  first  to  make  injections  into  the  trunks  of  the  nerves  at  the 
base  of  the  skull  in  treating  trifacial  neuralgia.  Ostwalt  followed  him  and 
injected  the  three  branches  of  the  nerve  through  the  mouth.  Levy  and  Baudouin 
devised  and  systematized  a  simple  and  safe  method  for  making  the  injections 
without  incurring  the  dangers  incident  to  invading  the  mouth.  Patrick  has 
followed  their  method  with  much  success.  The  author  has  followed  Murphy's 
modification  of  the  L^vy-Baudouin  procedure  and  finds  it  easy  and  satisfactory, 

Ostwalt's  Injections  ("La  Presse  Med.,"  Dec.  i6,  1905). — Ostwalt  in- 
jects I  to  I  1/2  c.c.  of  80  per  cent,  alcohol  (to  which  is  added  .01  cocaine 
or  stovaine)  into  the  trunk  of  each  of  the  branches  involved  where  it  emerges 
from  the  skull.  "As  usually  several  branches  (most  commonly  the  second  and 
third)  are  affected  at  the  same  time,  I  make  an  injection  in  two  or  three  stages; 
first  at  the  foramen  ovale  then  at  the  foramen  rotundum  and  last,  if  necessary,  in 
the  sphenoidal  fissure.  To  reach  the  foramen  ovale,  I  introduce  my  bayonette- 
shaped  needle  (Fig.  39),  mounted  on  the  syringe,  behind  the  wisdom  tooth  and 
make  it  penetrate  the  mucosa,  submucosa  and  external  pterygoid  muscle,  then 

56 


INJECTIONS. 


57 


I  pass  it  up  into  the  pterygoid  fossa  along  the  external  wing  of  the  pterygoid 
process  until  it  strikes  the  great  wing  of  the  sphenoid.  I  then  direct  the  point  of 
the  needle  backwards  into  the  angle  formed  by  the  pterygoid  process  and  the 
great  wing  of  the  sphenoid  until  bony  resistance  disappears,  and  the  foramen 
ovale  is  reached.  As  soon  as  the  fluid  is  injected  here  I  conduct  the  needle, 
always  in  the  above-mentioned  angle  of  the  pterygoid  fossa,  forwards  until  once 
more  the  sense  of  bony  resistance  is  lost.  The  needle  is  now  at  the  border  of  the 
sphenomaxillary  fossa.  Keeping  the  needle  continCiously  on  the  anterior  surface 
of  the  pterygoid  fossa  I  push  the  needle  upwards  6  to  9  m.m.,  reaching  the  fora- 
men rotundum,  and  can  feel  the  upper  border  of  the  foramen  formed  by  the 
little  osseous  bridge  which  separates  it  from  the  sphenoidal  fissure.  In  the  rare 
cases  where  the  first  branch  is  involved  along  with  the  second  or  with  the  second 


Fig.  39. — (Ostwalt.) 

and  third  branches,  it  is  only  necessary  (once  the  injection  of  the  superior 
maxillary  is  completed)  to  pass  the  needle  about  2  m.m.  higher,  passing  above 
the  little  osseous  bridge  already  mentioned,  where  it  encounters  the  ophthalmic 
branch  in  its  passing  through  the  sphenoidal  fissure."  Ostwalt  has  made  250 
deep  injections  in  tic  without  any  ill  effect.  In  at  least  one-third  of  the  cases 
there  was  recurrence  at  the  end  of  four  or  five  months,  but  these  recurrences 
were  less  serious  than  the  original  tic  and  were  relieved  by  one  or  two  more 
injections.  Although  as  a  rule  one  injection  gives  improvement  in  tic,  yet  two, 
three  or  four  seances  are  generally  required. 

Levy  and  Baudouin  write  ("La  Presse  Med.,"  Feb.  17,  1906):  "We  have 
used,  experimentally  and  clinically,  alcohol  and  chloroform  in  which  we  have 
dissolved  sublimate  or  carbolic  in  the  proportion  of  i  per  cent."  [One  per 
cent,  of  sublimate  is  evidently  a  mistake — Author.]  "We  do  not  employ  osmic 
acid  for  fear  of  necrosis.  The  following  is  our  practice.  We  inject  i  or 
2  c.c.  of  alcohol  (with  or  without  cocaine)  of  increasing  strength — 70,  80, 
90  per  cent.;  then  we  repeat  the  injections  of  these  strengths  of  alcohol 
after  adding  4  drops  of  chloroform  to  each  c.c.  of  alcohol.  Experiments 
on  animals  show  that  these  substances  in  the  doses  employed  by  us  are 
harmless  even  when  injected  intravenously.  The  puncture  itself  is  but 
slightly  painful.  Generally  when  the  nerve  trunk  is  reached  the  patient  com- 
plains of  a  pain  through  the  corresponding  territory.   .    .    .     The  injection 


58  TIC    DOULOUREUX. 

should  be  made  very  slowly  and  the  needle  ought  not  to  be  withdrawn  for  fifteen 
or  twenty  seconds.  .  .  .  After  from  two  to  five  minutes  the  patient  complains 
of  a  feeling  of  stiffness,  of  swelling,  then  of  numbness  in  the  territory  of  the  in- 
jected nerve.  Sometimes  one  can  demonstrate  a  complete  anesthesia  which 
may  persist  for  a  long  time.  Usually  the  injection  is  followed  by  an  exacerbation 
of  the  pain  for  some  hours  and  the  patient  ought  to  be  warned  of  this.  In  the 
region  of  the  injection  there  is  a  slight  temporary  edema  and  after  injection  of 
the  inferior  maxillary  nerve  there  is  a  certain  difficulty  in  opening  the  mouth. 
As  a  rule  six  or  eight  injections  are  required  at  intervals  of  three  or  four  days. 
The  tolerance  of  the  patient  must  regulate  the  time  and  strength  of  the  injection. 
Experience  has  taught  us  that  it  is  necessary  to  inject  at  least  two  of  the  branches 
of  the  trifacial  nerve.  In  case  of  neuralgia  of  the  inferior  maxillary  or  of  the 
ophthalmic  nerves,  the  superior  maxillary  ought  also  to  be  injected.  In  case  of 
neuralgia  of  the  superior  maxillary  we  inject  the  inferior  maxillary  also."  J. 
B.  Murphy  uses  from  seven  to  fifteen  minims  of  a  2  per  cent,  solution  of  osmic 
acid  as  an  injection  material.  The  author  has  had  the  pleasure  of  seeing  some 
of  the  excellent  results  secured  by  Murphy. 

The  Operation. — The  only  special  instrument  required  is  the  Levy- 
Baudouin  cannula.  The  cannula  is  of  steel  10  cm.  long,  i  1/2  mm.  in  diameter 
(Fig.  40),  and  is  graduated  in  centimeters.     The  mandrin  with  which  the  can- 


—  I   —  I  ^ 


L^'      t  I  I 

Fig.  40. 

nula  is  provided,  when  pushed  home  protects  the  sharp  point  of  the  cannula 
so  that  no  injury  can  be  inflicted  on  such  structures  as  arteries. 
A.  Injection  of  the  Inferior  Maxillary  Nerve. 

1.  Levy-Baudonin  Method. — -Note  the  bony  prominence  at  the  junction 
of  the  zygoma  with  the  anterior  bony  wall  of  the  external  auditory  meatus. 
Choose  a  point  on  the  lower  edge  of  the  zygoma  2.5  cm.  anterior  to  the  above 
bony  prominence.  At  this  point  introduce  the  cannula  directly  inwards  and 
immediately  under  (in  contact  with)  the  zygoma  for  a  depth  of  4  cm.  when  its 
point  must  be  at  the  foramen  ovale.  To  avoid  injuring  the  middle  meningeal 
artery,  push  the  mandrin  home  in  the  cannula  (thus  rendering  the  instrument 
blunt)  as  soon  as  a  depth  of  1.5  cm.  is  reached,  retire  the  mandrin  when  the 
depth  of  4  cm.  is  attained,  and  inject  the  chosen  solution. 

2.  Murphy's  Method. — Choose  a  point  at  the  middle  of  the  upper  edge 
(Figs.  41  and  42)  of  the  zygoma  and  here  introduce  the  needle  passing  it 
directly  inwards  until  it  strikes  either  the  squamous  portion  of  the  temporal 
bone  or  the    great  wing  of  the  sphenoid  and  guided  by  these  passes  inevitably 


INJECTIONS. 


59 


over  the  foramen  ovale  at  a  depth  of  i  1/2  inches  (4  cm.)  from  the  outer  surface 
of  the  zygoma. 

B.  Injection  of  the  Superior  Maxillary  Nerve. 

I.  Levy-Baudouin  MetJiod. — Prolong  the  line  of  the  posterior  border  of  the 
ascending  (orbital)  process  of  the  malar  bone  to  the  lower  edge  of  the  zygoma 


Fig.  41. 


Fig. 


and  insert  the  needle  1/2  cm.  posterior  to  this  point.  Direct  the  needle  inwards 
and  slightly  upwards  in  a  direction  which  would  attain  at  the  depth  of  the  fora- 
men rotundum  (5  cm.),  the  level  of  the  inferior  extremity  of  the  nasal  bone. 
When  the  needle  has  penetrated  5  cm.  its  point  has  reached  the  nerve  where 
it  emerges  from  the  foramen  rotundum  into  the  pterygo-maxillary  fossa. 


6o  TIC   DOULOUREUX. 

2.  Murphy's  Method. — Draw  an  imaginary  line  vertically  downwards  from 
the  external  angular  process  of  the  frontal  bone;  where  this  line  crosses  the 
inferior  margin  of  the  zygoma  introduce  the  needle  directly  under  the  zygoma. 
Pass  the  needle  inwards  and  a  trifle  upwards  until  it  impinges  against  the  back 
of  the  superior  maxilla.  Guided  by  the  maxillary  bone  push  the  needle  on 
until  its  point  has  penetrated  i  3/4  inches  (41/2  cm.)  or  slightly  more  from 
the  surface  of  the  malar  and  has  reached  the  foramen  rotundum. 

C.  Injection  of  the  Ophthalmic  Nerve. 

Levy-Baudouin  Method. — These  authors  write:  "The  first  branch  of  the 
fifth  pair  dividing  inside  the  cranium  one  cannot  attack  its  trunk.  Of  the  three 
branches  the  nasal  is  hardly  accessible  in  the  midst  of  the  important  motor 
nerves  which  surround  it.  To  reach  the  frontal  and  lachrymal  nerves  the  orbital 
route  is  indicated.  As  a  path  to  the  nerve  we  have  chosen  the  external  wall  of 
the  orbit  at  the  level  of  the  inferior  extremity  of  the  external  angular  process  of 
the  frontal  bone.  Inserted  here  the  needle  passes  below  the  lachrymal  gland  and 
follows  the  periosteum  without  injury  to  the  eye  or  to  any  important  organ. 
At  a  depth  of  35  or  40  mm.  one  makes  the  injection  after  withdrawing  the 
mandrin.  The  patient  ought  to  have  his  eyes  closed.  The  needle  has  some 
difficulty  in  penetrating  the  outer  portion  of  Tenon's  capsule  which  is  very 
thick." 

Hugh  Patrick  has  had  much  experience  in  the  use  of  deep  injections  of 
alcohol  for  the  relief  of  tic  and  makes  some  characteristically  cautious  and 
sensible  remarks  thereon  ("Journal  A.  M.  A.,"  Sept.  19,  1907),  a  synopsis  of 
which  is  given  here : 

The  number  of  injections  necessary  for  relief  depends  on  the  accuracy  with 
which  the  alcohol  is  placed.  A  single  injection  wdthin  the  nerve  sheath  will 
stop  the  pain  at  once.  A  number  of  trials  may  be  necessary  before  this  can  be 
accomplished.  An  injection  near  though  not  in  the  nerve  is  not  without  value 
because  the  alcohol  "undoubtedly  diffuses  sufficiently  to  reach  it.  In  such 
cases  the  relief  comes  after  some  minutes  or  hours  and  does  not  last  long. 
Consequently  I  believe  it  is  wise  to  continue  the  injections  even  though  the 
patient  is  having  no  pain,  until  the  characteristic  sensory  phenoma"  (pain  and 
feeling  of  swelling  and  stiffness  in  the  area  supplied  by  the  nerve;  analgesia  in 
area)  "announce  marked  action  on  the  nerve."  If  pain  returns  there  seems  to 
be  no  objection  to  secondary  injections.  In  conversation  with  the  author 
Patrick  gave  the  impression,  no  doubt  correct,  that  a  permanent  cure  could 
hardly  be  expected  from  injections;  but  the  operation  is  trivial,  usually  gives  at 
least  temporary  relief  and  may  be  apparently  repeated  indefinitely. 

Fischer  (Munchener  med.  Woch.,"  1907,  No.  32)  reporting  the  result  of 
injections  of  alcohol  in  Erb's  clinic  for  various  neuralgias  warns  against  their 
use  in  mixed  or  in  motor  nerves  as  dangerous  consequences  have  arisen;  yet 
Patrick  and  others  have  injected  alcohol  into  the  facial  nerve  with  good  results 
in  facial  spasm  (not  tic)  without  causing  troublesome  facial  paralysis. 


NEURECTOMY.  6l 

NEURECTOMY  OF  THE  FIRST  DIVISION  OF  THE 
FIFTH  NERVE. 

The  first  or  ophthalmic  division  of  the  fifth  nerve  enters  the  orbit  through 
the  sphenoidal  fissure  and  divides  into  three  branches — the  frontal,  lachrymal, 
and  nasal.  The  frontal  nerve,  the  only  branch  of  surgical  importance,  divides 
into  the  supraorbital  and  supratrochlear.  The  supraorbital  leaves  the  orbit 
through  a  notch  or  foramen  situated  at  the  junction  of  the  inner  and  middle 
thirds  of  the  supraorbital  margin.  With  it  run  the  supraorbital  artery  and 
vein. 

NEURECTOMY  OF  THE  SUPRAORBITAL  NERVE. 

Locate  the  supraorbital  notch  or  foramen.  Make  a  horizontal  incision 
through  the  skin,  parallel  to  and  a  little  below  the  eyebrow.  Separate  the 
fibres  of  the  orbicularis  muscle.  Expose  the  nerve  as  it  passes  through  the 
supraorbital  notch.  Divide  the  orbitotarsal  ligament.  With  a  flat  retractor 
depress  the  orbital  fat.  Follow  the  nerve  backwards  from  the  supraorbital 
notch,  separate  it  from  its  surroundings,  divide  it  as  far  back  as  possible,  and 
remove  all  of  it  in  front  of  the  point  of  section.  Close  the  wound  -wdth  sutures. 
Dress. 

A  good  modification  of  the  operation  is  the  following:  Expose  the  nerve 
at  its  exit;  isolate  it  for  a  short  distance;  seize  its  undivided  trunk  with  a  narrow- 
bladed  hemostat;  rotate  the  hemostat  so  that  the  nerve  becomes  wound  around 
the  jaws  of  the  forceps;  reverse  the  direction  of  rotation.  By  repeating  the 
manoeuvres  of  rotation  and  working  slowly  and  patiently  almost  the  whole 
peripheral  portion  of  the  nerve  and  much  of  its  central  trunk  can  be  extracted. 
(Thiersch.)  , 

NEURECTOMY  OF  THE  SUPRATROCHLEAR. 

The  supratrochlear  nerve  is  generally  di\'ided  in  the  preceding  operation, 
but  occasionally  it  is  missed  and  demands  special  attention.  Draw  an  imagi- 
nary line  from  the  angle  of  the  mouth  through  the  irmer  canthus  of  the  eye. 
At  a  point  a  little  below  where  a  continuation  of  the  above  line  crosses  the 
eyebrow  make  an  incision  through  the  skin  parallel  to  the  fibres  of  the  or- 
bicularis muscle.  Find  the  trochlea,  which  acts  as  a  pulley  for  the  superior 
oblique  muscle.  Locate  the  posterior  portion  of  the  superior  oblique  muscle. 
The  supratrochlear  nerve  and  its  branch,  the  infratrochlear,  lie  upon  the 
superior  oblique  muscle  and  may  be  separated  from  it  by  a  strabismus  hook 
and  excised. 

NEURECTOMY  OF  THE  SECOND  DIVISION  OF  THE 
FIFTH  NERVE. 

Anatomy. — The  superior  maxillary  nerve  "commences  at  the  middle 
of  the  Gasserian  ganglion,  and,  passing  horizontally  forwards,  soon  leaves 


62 


TIC    DOULOUREUX. 


the  skull  by  the  foramen  rotundum  of  the  sphenoid  bone.  The  nerve  then 
crosses  the  sphenomaxillary  fossa,  and,  taking  the  name  of  infraorbital,  enters 
the  infraorbital  canal  of  the  upper  maxilla,  by  which  it  is  conducted  to  the 
face"  (Fig.  43). 

"In  the  sphenomaxillary  fossa  an  orbital  or  temporo-malar  branch  ascends 
from  the  superior  maxillary  nerve  to  the  orbit,  and  two  sphenopalatine  branches 
descend  to  join  Meckel's  ganglion;  while  the  nerve  is  in  contact  with  the  up- 
per maxilla  it  furnishes  the  superior  dental  or  alveolar  branches;  and  on  the 
face  are  the  terminal  branches"  (Quain). 


,-  ophthalmicus 
supramaxiUaris 
Gg.  sphenopalai  , 
For.  oval. 


-HnframaxUlaris 


Fig.  43. — {Esmarch  and  Kowalzig.) 


When  the  neuralgia  is  limited  to  the  facial  distribution  of  the  nerve,  the 
following  operations  may  be  performed: 

(A)  Locate  the  infraorbital  foramen  at  the  junction  of  the  inner  and  middle 
thirds  of  the  inferior  rim  of  the  orbit  and  about  half  an  inch  below  it.  It  is 
on  a  line  drawn  from  the  supraorbital  notch  to  a  point  between  the  two  bicus- 
pids. Make  a  curved  transverse  incision  parallel  and  close  to  the  lower 
margin  of  the  orbit.  Divide  the  orbicularis  muscle  in  a  direction  parallel 
to  its  fibres.  Expose  the  nerve  as  it  leaves  the  infraorbital  foramen  (Fig.  44). 
Seize  the  nerve  in  forceps,  and  by  traction  and  torsion  extract  as  much  of  its 
trunk  from  its  bony  canal  as  is  possible.     In  the  same  fashion  extract  as  much 


NEURECTOMY. 


63 


of  its  terminal  twigs  as  possible  from  the  soft  structures  in  which  they  run. 
It  is  extraordinary  how  much  of  the  nerve  can  be  removed  in  this  manner  if 
patience  is  exerted.  This  operation  does  not  destroy  the  alveolar  branches 
of  the  nerve.  In  an  endeavor  to  prevent  recurrence  one  may  plug  the  bony 
canal  with  a  bone  peg,  silver  screw,  rubber  tissue,  or  amalgam. 


Fig.  44. 

(B)  Expose  the  nerve  as  in  Method  A.  Opposite  the  infraorbital  foramen 
make  a  vertical  incision  (a)  through  the  soft  parts  joining  the  horizontal 
incision  at  right  angles  (Fig.  45).  Divide  the  periosteum  along  the  lower 
margin  of  the  orbit.  Separate  the  periosteum  covering  the  floor  of  the  orbit 
from  the  bone.     If  this  is  done,  no  orbital  fat  should  be  seen.     With  a  flat 


Fig.  45. — (Esmarch  and  Kowalzig.) 


Fig.  46. — {Esmarch  and  Kowalzig.) 


retractor  lift  the  orbital  contents  upwards  (Fig.  46).  With  a  narrow  chisel 
cut  through  the  bone  all  round  the  infraorbital  foramen  and  remove  it  until 
that  part  of  the  osseous  canal  which  is  covered  by  a  thin  shell  of  the  bone  form- 
ing the  orbital  floor,  is  exposed.  With  the  chisel  cut  away  the  bony  roof  of 
the  infraorbital  canal  to  its  posterior  extremity.  This  can  generally  be  accom- 
plished  without   opening  the  antrum  of  Highmore.     Lift  the  nerve  from  its 


64 


TIC   DOULOUREUX. 


bed  and  excise  it.  Close  the  wound  with  sutures.  Dress.  The  scar  left 
by  the  operation  is  trifling.  Several  operations  have  been  devised  to  excise 
the  superior  maxillary  nerve  and  Meckel's  ganglion  by  the  antral  route.  Any 
operation  in  which  the  antrum  of  Highmore  is  opened  is  undesirable  on  the 
score  of  uncleanliness,  and  the  advantages  of  such  methods  are  more  fully 
obtained  by  the  operation  about  to  be  described. 

Pterygo-maxillary  Operation.  (Braun  and  Lossen's  Modification 
of  Lucke's  Operation.) — Step  i. — Expose  the  infraorbital  nerve  at  its  exit 
from  the  bone. 

Step  2. — Beginning  at  a  point  just  behind  and  below  the  external  angular 
process  of  the  frontal  bone,  make  an  incision  backwards  and  downwards 
to   near   the   tragus.     From   the   same   starting-point   make  another  incision 

downwards  and  forwards  to  the  lower 
margin  of  the  zygoma.  Reflect  down- 
wards the  triangular  flap  of  skin  and  sub- 
cutaneous tissue  thus  outlined.  With  a 
finger  saw,  chisel,  or  Gigli  wire  saw  divide 
the  zygoma  in  front  and  behind.  Rose 
recommends  that  before  the  zygoma  is 
divided  holes  be  bored  on  each  side  of 
the  line  of  section  so  that  everything  may 
be  ready  for  wiring  the  fragments  in 
position  on  the  completion  of  the  active 
part  of  the  operation.  Separate  the 
temporal  fascia  from  the  upper  edge  of 
the  zygoma  and  turn  the  bone  down- 
wards. Retract  the  tendon  of  the  tem- 
poral muscle  backwards.  The  pterygo- 
maxillary  fossa  is  exposed,  with  its  fat 
and  plexus  of  veins.  If  one  now  pushes 
the  fat  back  with  a  blunt  retractor,  one  at  the  same  time  keeps  the  venous 
plexus  and  internal  maxillary  artery  out  of  the  way.  Demonstrate  the 
posterior  orbital  fissure  with  a  probe  or  strabismus  hook  and  distinguish  the 
superior  maxillary  nerve  and  its  accompanying  vessel  (Fig.  47).  The  course 
of  the  nerve  from  its  exit  from  the  skull  is  downwards,  forwards,  and  outwards. 
The  artery  runs  inwards,  forwards  and  upwards. 

Step  3. — Tie  a  ligature  round  the  nerve  for  purposes  of  traction.  Divide 
the  central  end  of  the  nerve  as  close  to  the  foramen  rotundum  as  possible. 
By  traction  and  torsion  pull  the  peripheral  end  of  the  nerve  out  of  its  bony 
canal.  By  this  operation  the  whole  trunk  of  the  nerve  is  excised  from  the 
foramen  rotundum  to  the  cheek. 

Step  4. — Attend  to  hemostasis.  Replace  the  zygoma  and  fix  it  in  position 
by  wire  or  chromicized  catgut  sutures.  Provide  drainage.  Close  the  skin 
wound.     Dress. 


NEURECTOMY.  65 

NEURECTOMY  OF  THE  THIRD  DIVISION  OF  THE  FIFTH. 

The  inferior  maxillary  or  third  division  of  the  fifth  nerve  leaves  the  skull 
through  the  foramen  ovale  and  divides  into  an  anterior,  motor  and  a  poste- 
rior division.  The  latter,  almost  entirely  sensory,  divides  into  the  auriculo- 
temporal, the  lingual,  and  the  inferior  dental.  The  lingual  and  the  inferior 
dental  are  of  surgical  importance,  and  as  they  are  generally  both  involved, 
if  either  of  them  is  afifected  by  neuralgia,  their  excision  may  be  considered  as 
part  of  one  operation.  (See  Fig.  43.)  Only  one  method  of  excising  portions 
of  the  lingual  and  inferior  dental  nerves  will  be  described,  as  it  is  so  superior 
to  any  other  method  devised. 

The  Operation. — Shave  the  temple.  Clean  the  side  of  the  face  and  the 
external  auditory  meatus,  and  plug  the  latter  passage  with  a  little  gauze  or 
better  with  non-absorbent  cotton. 

Step  I. — Beginning  about  the  middle  of  the  zygoma  cut  backwards  and 
slightly  downwards  to  a  point  a  little  below  the  tragus,  then  continue  the  in- 
cision downwards  along  the  posterior  margin  of  the  ascending  ramus  to  the 
angle  of  the  lower  jaw.  From  this  point  cut  forwards  along  the  inferior  edge 
of  the  horizontal  ramus  for  about  3/4  inch.  The  cut  only  involves  the  skin 
and  subcutaneous  tissue.  Reflect  the  skin-flap,  outlined  as  above,  forwards. 
The  flap,  consisting  of  skin  alone,  leaves  the  branches  of  the  facial  nerve  un- 
injured. Note  carefully  the  position  of  Stenson's  duct  and  of  the  anterior 
lobules  of  the  parotid  gland.  Make  a  transverse  incision  parallel  to  and 
below  Stenson's  duct,  directly  down  to  the  bone,  at  a  point  about  1/2  inch 
below  the  sigmoid  notch.  Any  portions  of  the  parotid  gland  which  may  be 
in  the  way  must  be  retracted  backwards  uninjured. 
With  a  periosteal  elevator  denude  the  outer  surface 
of  the  ascending  ramus  of  the  jaw  for  a  distance  of 
one  inch  or  more  below  the  sigmoid  notch. 

Step  2. — Apply  a  3/4  inch  trephine  to  the  outer 
surface  of  the  bone,  the  upper  edge  of  the  trephine 
being  not  more  than  1/4  inch  below  the  edge  of  the 
sigmoid  notch  (D,  Fig.  48).  With  the  trephine 
perforate    the    ascending    ramus    and    remove    the 

button  of  bone.  With  rongeur  forceps  remove  the  bridge  of  bone  (C,  Fig.  48), 
separating  the  trephine  hole  from  the  sigmoid  notch.  The  result  of  the  above 
manoeuvres  is  to  deepen  the  sigmoid  notch  while  the  coronoid  and  articular 
processes  are  left  in  uninterrupted  connection  with  the  rest  of  the  jaw. 

Step  3. — Retract  the  tendon  of  the  temporal  muscle  forwards.  With 
two  pairs  of  dissecting  forceps  pick  away  any  fat  which  may  be  in  the  way  and 
demonstrate  the  external  pterygoid  muscle,  which  passes  transversely  across 
the  wound  from  the  outer  surface  of  the  external  pterygoid  plate  to  the  articular 
process  of  the  lower  jaw.  Note  also  the  fibres  of  the  internal  pterygoid  run- 
ning downwards  and  backwards  from  the  pterygoid  fossa  to  the  inner  surface 
5 


66  TIC   DOULOUREUX. 

of  the  lower  jaw  near  its  angle.  Retract  upwards  the  lower  fibres  of  the 
external  pterygoid  and  thus  expose  both  the  lingual  and  inferior  dental  nerves, 
which,  resting  upon  the  internal  pterygoid  muscle,  come  out  from  under  the 
external  pterygoid  and  run  downwards.  The  lingual  nerve  lies  a  little  internal 
and  anterior  to  the  dental.  Tie  a  ligature,  for  purposes  of  traction,  round 
each  nerve.  Trace  the  nerves  up  to  the  foramen  ovale  and  divide  them  there. 
Trace  the  nerves  downwards  and  either  divide  them  or  by  torsion  and  traction 
tear  away  as  much  of  their  peripheral  portion  as  can  be  extracted.  It  is  easy 
to  remove  more  than  an  inch  of  the  nerves. 

Step  4. — Attend  to  hemostasis.  Close  the  skin-wound.  Drainage  may  or 
may  not  be  used.     Dress. 

Inferior  Dental  Nerve.  Transmaxillary  Neurectomy. 
Step  I. — From  the  angle  of  the  lower  jaw  make  an  incision  for  about  i  1/2 
inches  forwards  along  the  lower  border  of  the  horizontal  ramus.  With  an 
elevator  separate  the  masseter  from  the  bone.  If  necessary  continue  the 
incision  upwards  along  the  posterior  border  of  the  ascending  ramus  for  about 
3/4  inch.  Expose  the  greater  part  of  the  external  surface  of  the  ascending 
ramus. 

Step  2. — Note  the  line  of  the  free  border  of  the  teeth  of  the  lower  jaw  and 
continue  this  as  an  imaginary  line  across  the  ascending  ramus;  on  this  line 

choose  a  spot  midway  between  the  anterior 
and  posterior  borders  of  the  ramus  and  at 
this  spot  apply  a  Doyen's  bur  (about  16 
mm.  in  diameter)  and  bore  a  hole  suffi- 
ciently deep  to  expose  the  inferior  dental 
canal  and  the  nerve  in  it.  The  bur  is  a 
better  instrument  to  use  than  a  trephine  as 
it  is  not  so  liable  to  injure  the  nerve. 
Step  3. — The  nerve  is  seen  lying  in  the 
^^^_  depth  of  the  wound  (Fig.    49).      Pick  up 

„  ,r  ..  the  nerve  in  a  forceps  and  evulse  it  after 

Fig.  49. — {Lenormam.)  ^ 

the  manner  of  Thiersch.  Pack  the  bone 
canal  with  rubber  tissue,  hard  paraffin,  amalgum  or  some  such  material. 

Step  4. — Close  the  wound. 

The  author  has  found  this  operation  very  satisfactory. 

All  the  operations  of  neurectomy  which  have  been  described  give  at 
least  temporary  relief,  but  too  frequendy  the  tic  returns  after  the  lapse  of  a 
year  or  two.  Occasionally  the  patient  does  not  seem  to  get  immediate  relief 
from  his  pains.  The  author  has  in  mind  one  case  in  which  he  removed  por- 
tions of  the  inferior  dental  and  lingual  nerves.  The  patient  suffered  from 
neuralgia  for  one  or  two  days  after  the  operation.  The  pain  was  at  once 
relieved  on  the  removal  of  bloody  fluid  which  had  collected  in  the  deep  wound. 
Had  the  wound  been  efficiently  drained,  the  temporary  trouble  might  have 
been  averted. 


HARTLEY-KRAUS    OPERATION.  67 

None  of  the  operations  of  neurectomy  for  tic  douloureux  which  have  been 
described  here  are  dangerous  when  performed  by  an  experienced  surgeon, 
but  they  are  not  a  proper  field  for  invasion  by  a  tyro  in  surgery.  In  almost  all 
the  operations  the  wounds  while  large,  are  so  situated  as  to  cause  but  little 
deformity  from  scar,  especially  if  the  subdermal  suture  is  used  in  closing  them. 

HARTLEY-KRAUSE    OPERATION. 

It  has  been  shown  that  tic  douloureux  very  frequently  recurs  after  even 
the  most  extensive  excision  of  the  nerve-trunks  involved.  It  has  also  been 
shown  (Keen  and  Spiller)  that  in  the  Gasserian  ganglion  very  marked  degen- 
eration is  present.  When  neurectomy  fails  to  give  permanently  good  results,  it 
is  most  logical  to  attack  the  Gasserian  ganglion.  This  has  been  done  in  many 
cases  with  excellent  effect.  The  Gasserian  ganglion  may  be  exposed  either 
from  below  or  from  above.  The  former  method  has  been  thoroughly  studied 
by  Rose,  Andrews,  and  others.  Their  route  entails  temporary  resection  of 
the  zygoma  and  the  coronoid  process,  the  use  of  the  inferior  maxillary  nerve 
as  a  guide  to  the  foramen  ovale,  exposure  of  the  base  of  the  skull  beside  that 
opening,  the  removal  of  a  button  of  bone  from  the  exposed  portion  of  skull 
with  a  trephine,  and  lastly  a  rather  haphazard  removal  of  the  ganglion  when 
it  is  reached.  Anyone  who  has  had  occasion  to  operate  in  the  neighborhood 
of  the  foramen  ovale  can  appreciate  the  difficulties  of  the  operation.  Hartley 
and  Krause  almost  simultaneously  devised  a  method  of  reaching  the  Gasserian 
ganglion  by  an  intracranial  route.  Their  operation  is  so  much  better  than 
the  others  that  it  will  be  described  here. 

The  Operation. — Shave  at  least  one-half  of  the  patient's  head.  Clean 
the  head,  face,  and  external  auditory  meatus.  Pack  the  external  auditory 
meatus  with  aseptic  gauze  or  non-absorbent  cotton. 

Step  I. — As  there  are  several  methods  of  performing  this  step,  they  will 
be  taken  up  seriatim. 

Method  A. — Beginning  on  the  zygoma  immediately  in  front  of  the  tragus, 
make  an  incision  upwards,  directly  to  the  bone.  Make  the  incision  run  a 
curved  course  (convexity  upwards)  and  end  on  the  zygoma  at  a  point  about 
I  1/2  inches  in  front  of  the  starting  place.  The  curved  incision  outlines  a 
flap  2  1/2  inches  in  height,  2  inches  wide  at  its  broadest  part,  and  having  a 
pedicle  i  1/2  inches  wide.  The  flap  is  shaped  somewhat  like  a  uterus.  Check 
the  bleeding.  With  a  chisel  and  mallet  or  a  gouge,  having  a  V-shaped  cutting- 
edge,  divide  the  skull  along  lines  corresponding  to  the  wound  in  the  soft  parts. 
When  the  skull  has  been  completely  divided,  raise  the  bone  and  soft  parts 
adherent  to  it  (skin,  temporal  muscle,  periosteum)  and  turn  them  downwards, 
breaking  the  bridge  of  bone  opposite  the  pedicle.  The  soft  parts  act  as  a 
hinge.  The  line  of  fracture  where  the  bone-flap  is  reflected  is  opposite  the 
zygoma,  and  hence  is  at  a  higher  level  than  the  base  of  the  skull.  With  rongeur 
forceps  cut  away  the  bone  immediately  below  the  opening  in  the  skull,  until 


68  TIC    DOULOUREUX. 

the  true  floor  of  the  middle  fossa  of  the  skull  is  reached.  This  removal  of 
bone  after  the  bone-flap  has  been  reflected  is  a  very  important  step  in  the 
operation. 

Method  B. — Much  time  may  be  saved  by  using  a  circular  saw  or  protected 
drill  driven  by  an  electric  motor  or  surgical  engine,  instead  of  the  chisel  and 
mallet.     Comparatively  few  surgeons  possess  such  apparatus. 

Method  C. — Krause  suggests  the  following  method  in  cases  where  it  is 
imperative  to  avoid  loss  of  blood.  Have  an  assistant  exercise  pressure  on 
the  temporal  artery.  With  a  knife  make  an  incision 
directly  to  the  bone  corresponding  to  the  upper 
margin  of  the  flap  to  be  reflected.  Through  this 
cut  separate  the  soft  parts  from  the  bone,  with  a 
periosteal  elevator,  down  to  the  level  of  the  zygoma. 
Rapidly  make  the  anterior  and  posterior  incisions  of 
the  flap.  Attend  to  hemostasis.  By  the  above  means 
hemorrhage  from  the  soft  parts  is  avoided.  Open 
the  skull  with  a  trephine.  Remo v  e  as  much  bone  with 
rongeur  forceps  as  is  reflected  or  removed  in  Method 
Fig.  50.  A.     This  method  has  a  very  limited  application  and 

leaves  marked  deformity,  as  no  bone  is  replaced. 
Method  D. — Trace  by  an  imaginary  line  on  the  temple  the  flap  A,  B,  C,  D, 
of  similar  shape  and  in  the  same  position  as  that  described  in  Method  A. 
Join  the  points  A  and  B  (Fig.  50)  by  an  incision,  cutting  directly  to  the  bone. 
At  the  points  A  and  B  perforate  the  skull  by  means  of  a  Doyen  perforator 
or  small  trephine.  With  a  dural  separator  the  dura  from  the  bone  between 
the  perforations.  Pass  a  slightly  curved  grooved  director  between  the  dura 
and  the  bone  from  the  opening  A  to  the  opening  B.  Along  the  grooved 
director  pass  a  Gigli  wire  saw.  The  ends  of  the  wire  saw  emerge  at  A  and 
B.  The  loop  of  the  wire  lies  against  the  inner  surface  of  the  skull  between 
A  and  B.  The  cranial  contents  are  protected  by  the  director.  Saw  through 
the  skull  between  A  and  B,  cutting  from  within  outwards.  With  a  knife 
make  the  cuts  AC  and  BD.  Catch  up  all  bleeding  points  in  forceps  as  soon 
as  they  are  observed.  With  narrow-bladed  rongeur  forceps  (Dahlgren's, 
Keen's,  etc.)  divide  the  bone  along  the  lines  AC  and  BD.  There  is  now  a 
flap  consisting  of  bone  and  superjacent  soft  structures  which  may  be  reflected 
downwards  by  breaking  the  bone  along  the  line  CD.  The  rest  of  Method  D 
is  identical  with  Method  A. 

Step  2. — In  the  preceding  step  the  bone  has  been  removed  down  to  the 
more  or  less  horizontal  base  of  the  skull.  With  the  finger  quickly  separate 
the  dura  from  the  bone  until  the  foramen  spinosum  and  middle  meningeal 
artery  are  reached.  Krause  finds  that  quick  work  with  the  finger  is  without 
danger  and  produces  less  venous  bleeding  than  slow  separation  with  a  blunt 
raspatory.  However  done,  there  is  much  venous  bleeding  which  is  stanched 
by  pressure  with  gauze.     When  the  foramen  spinosum  is  reached  (Fig.  5i)j 


HARTLEY-KRAUSE    OPERATION. 


69 


gently  lift  the  brain,  covered  by  dura  mater,  with  a  spatula,  whose  blade,  about 
I  1/4  inches  wide,  is  bent  at  a  right  angle.  The  brain  is  retracted  sufficiently 
to  give  a  good  view  of  the  deep  structures  to  be  attacked.  Isolate  the  middle 
meningeal  artery  at  the  foramen  spinosum,  doubly  ligate  and  divide  it.  Often 
the  artery  runs  in  a  very  deep  groove  or  even  in  a  canal  in  the  skull  and  there- 
fore becomes  torn  while  the  bone  is  being  removed.  Again,  the  vessel  may 
be  torn  at  its  exit  from  the  foramen  spinosum.  In  such  circumstances  bleed- 
ing may  be  stopped  by  pushing  into  the  foramen  or  canal  a  thin  strip  of  gauze 
by  means  of  a  blunt-pointed  instrument.  The  end  of  the  gauze  strip  must 
of  course  be  brought  out  of  the  wound  to  allow  of  subsequent  removal.     Instead 


Fig.  51. — (Krause.) 

of  gauze,  catgut  or  Horsley's  wax  may  be  used.  After  attending  to  the  middle 
meningeal  artery  continue  separating  the  dura  from  the  bone  in  the  direction 
of  the  ganglion.  This  is  done  with  a  blunt  instrument  or  with  small  pledgets 
of  gauze  held  in  hemostats.  Bleeding  is  free,  hence  from  time  to  time  it  is 
necessary  to  pack  a  little  gauze  underneath  the  flat  retractor  and  press  the 
gauze  against  the  bone  with  the  retractor  for  a  few  seconds.  A  slight  change 
in  the  position  of  the  retractor  often  causes  the  bleeding  from  the  dura  to 
cease.  The  ganglion  having  been  reached,  note  that  its  upper  surface  is  often 
firmly  adherent  to  the  dura.  Separate  these  adhesions  by  blunt  dissection. 
If   the   dura   is   injured,    cerebrospinal    fluid    escapes   but  no  harm   results. 


70  TIC   DOULOUREUX. 

Demonstrate  the  second  and  third  divisions  of  the  fifth  nerve  and  divide  them 
with  a  tenotome  at  the  foramen  rotundum  and  ovale  respectively.  Do  not  try  to 
demonstrate  the  first  division;  it  is  in  too  close  union  with  the  cavernous  sinus. 
If  bleeding  accompanies  division  of  ihe  second  and  third  divisions  of  the  nerve, 
it  is  easily  stopped  by  pressure  or  by  boring  a  blunt  instrument  into  their 
foramina.  Seize  the  posterior  portion  of  the  Gasserian  ganglion  transversely 
in  the  jaws  of  a  hemostat.  [It  is  well  to  do  this  after  the  second  and  third 
divisions  have  been  isolated  but  not  divided.  After  the  ganglion  is  fixed  by 
the  forceps  the  two  divisions  of  the  nerve  may  be  divided  at  their  foramina.] 
With  the  forceps  make  traction  along  the  axis  of  the  nerve.  This  extracts 
the  ganglion,  and  with  it  a  longer  or  shorter  portion  of  its  root. 

J.  Hutchinson,  Jr.,  advocates  division  of  the  superior  and  inferior  max- 
illary nerves  and  removal  of  the  corresponding  portion  of  the  ganglion,  leav- 
ing intact  the  ophthalmic  division  and  its  portion  of  the  ganglion  (Fig.  52). 

^^^^^^utchinson's  line  of  section. 

Ophthalmic  dimion.  ^^'^'   J  ^^^^'''^'^  Canjiion. 

Superior  Maxillary  j^^^^^^..  -g^'^°^^^  Meninjeal /Irtery. 
dii^ision.        "^^f^^-  1   -^^L^' 

MecKelh  Can^lio^^M^J^^  W^^^^^^^ 

^  Inferior  Maxillary  division. 

Fig.  52. — Left  Gasserian  Ganglion  Exposed  from  the  Side. 

Step  3. — Replace  the  brain  in  position.  Suture  the  temporal  flap  consist- 
ing of  bone  and  superjacent  soft  structures,  in  place.  Provide  drainage  if 
necessary  and  apply  dressings. 

Step  4. — ^For  several  weeks  after  the  operation,  danger  threatens  the  eye 
of  the  side  attacked,  if  for  no  other  reason  than  that  the  eye,  being  rendered 
anesthetic,  is  subject  to  injury  from  dust,  dressings,  etc.  Keen  recommends 
keeping  the  eye  clean  by  means  of  boracic-acid  lotion,  keeping  the  eyelid  closed 
by  one  or  two  stitches,  so  placed  that  while  the  eye  is  closed  the  boracic  lotion 
may  still  be  applied.  The  stitches  are  removed  from  the  eyelids  after  two  or 
three  days  and  the  eye  protected  by  a  watchglass  shield  held  in  place  by  ad- 
hesive plaster.  These  precautions  seem  entirely  competent  to  prevent  ocular 
trouble. 

Occasionally  when  performing  the  Hartley-Krause  operation  free  hem- 
orrhage or  the  low  condition  of  the  patient  demands  that  the  operation  be 
suspended.  Under  such  circumstances  the  wound  is  packed  with  gauze, 
dressed,  and  the  patient  kept  in  bed  for  a  few  days,  when  the  work  may  be 
resumed. 

The  Gasserian  ganglion  lies  close  to  the  cavernous  sinus,  and  this  structure 
has  been  wounded  on  more  than  one  occasion,  but  the  gush  of  blood  has 


cushing's  operation.  71 

always  been  easily  checked  by  gauze  pressure.     Fortunately  the  blood-pressure 
in  the  sinus  is  very  low. 

To  gain  a  nearer  approach  and  at  the  same  time  to  avoid  trouble  from  the 
middle  meningeal  artery  Gushing  exposes  the  Gasserian  ganglion  by  a  route 
lower  than  Hartley-Krause  and  higher  than  Rose.  The  method  is  similar 
to  that  of  Poirier,  but  less  severe. 

CUSHING'S  OPERATION. 

Step  I. — From  a  point  1/2  inch  behind  and  slightly  above  the  external 
angular  process  of  the  frontal  bone  make  a  curved  incision  down  to  the  zygoma, 
immediately  in  front  of  the  ear.  The  highest  point  reached  by  the  incision 
is  two  inches  above  the  zygoma.  Reflect  the  skin  downwards.  Resect  the 
zygoma  subperiosteally.  Make  a  curved  incision,  parallel  to  the  above, 
through  the  temporal  fascia  and  muscle.  Reflect  these  downwards,  exposing 
the  lower  part  of  the  temporal  fossa. 

Step  2. — With  chisel  or  gouge  open  the  skull  at  the  most  prominent  part 
of  the  exposed  great  wing  of  the  sphenoid.  With  rongeurs  enlarge  the  opening 
until  it  is  i  1/2  inches  in  diameter  and  extends  down  to  and  includes  the 
ridge  between  the  temporal  and  zygomatic  fossae.  The  middle  meningeal 
artery  lies  on  the  dura,  running  obliquely  across  the  opening  in  the  skull,  the 
lower  part  of  which  is  on  a  level  with  the  resected  zygoma. 

Step  3. — Lift  the  dura  and  the  artery  from  the  base  of  the  skull  until  the 
firm  attachment  of  the  former  at  the  foramen  ovale  is  reached.  Support 
the  cerebral  structures  gently  with  a  well-rounded,  pliable  spatula  or  retractor 
about  one  inch  wide,  which  should  be  held  by  the  surgeon  himself.  Using 
the  inferior  maxillary  nerve  as  a  guide,  split  the  sheath  of  the  ganglion  and 
expose  its  upper  surface. 

Step  4. — With  a  blunt  dissector  isolate  but  do  not  yet  divide  the  three  divi- 
sions of  the  trigeminus.  Isolate  the  ganglion  and  its  sensory  root.  Grasp 
the  ganglion  just  anterior  to  the  root  with  a  hemostat.  Lift  up  the  peripheral 
divisions  on  a  hook  and  divide  them.  Evulse  the  root  with  forceps.  During 
all  this  time  venous  bleeding  may  be  controlled  by  temporary  pressure  with 
gauze.  Gushing,  Brewer,  and  others  find  that  no  benefit  results  from  pre- 
liminary ligation  of  the  external  carotid  artery,  as  the  most  troublesome  bleed- 
ing is  venous.  It  is  a  needless  step,  therefore,  as  the  middle  meningeal  can  be 
avoided. 

Step  5. — Put  in  place,  when  necessary,  a  cigarette  or  protective  rubber 
drain.  Glose  the  wounds  in  the  muscle  and  fascia,  not  forgetting  the  fascial 
wound  made  in  resecting  the  zygoma.  Glose  the  skin-wound.  The  drain, 
if  one  has  been  used,  may  be  removed  in  forty-eight  hours. 

Abbe,  to  avoid  the  dangers  of  hemorrhage,  shock,  and  prolonged  operation, 
has  given  up  attempts  to  formally  resect  the  Gasserian  ganglion.  He  performs 
an   intracranical    neurotomy  or,   preferably,  neurectomy,    and  then  prevents 


72  TIC   DOULOUREUX. 

reunion  of  the  divided  nerves  by  interposing  a  layer  of  thin  rubber  tissue, 
sterilized  by  immersion  in  corrosive  sublimate  solution,  which  is  vi^ashed  off 
with  salt  solution.  To  lessen  hemorrhage  from  the  middle  meningeal  artery 
Abb^  ligates  the  external  carotid  just  above  the  thyroid. 

THE  ABBE  OPERATION. 

"Ligate  the  external  carotid;  make  a  straight  incision  in  the  temporal 
fossa  above  the  zygoma;  split  the  temporal  muscle,  scraping  it  widely  from  the 
bone,  and  enter  the  skull  by  a  small  trephine  opening,  rapidly  enlarged  by 
rongeurs  to  one  and  one-half  inches  in  diameter.  Expose  the  second  and 
third  branches  from  the  Gasserian  ganglion  to  the  foramina.  Seize  each  at 
the  foramen  by  a  narrow  clamp,  cut  it,  and  resect  a  half-inch  or  tear  it  from 
the  ganglion;  push  back  the  dura  well  beyond  the  foramina;  arrest  bleeding 
by  a  moment's  pressure,  and  spread  over  the  bone  a  piece  of  sterile  rubber 
tissue,  enough  to  more  than  cover  both  foramina,  one  inch  wide  by  an  inch 
and  a  half  in  length,  which  must  be  pressed  upon  the  bone  by  a  strip  of  gauze 
packed  over  it  for  a  couple  of  minutes.  When  this  is  removed,  the  rubber 
tissue  lies  in  close  contact  vnth  the  skull  and  the  dura  is  allowed  to  settle  down 
to  its  place  upon  it.  The  wound  is  then  closed  by  a  few  fine  catgut  sutures 
and  drained  for  a  day  at  its  lower  angle."     ("Trans.  Am.  Surg.  Assoc," 

1903-) 

G.  R.  Fowler  has  used  Crile's  plan  of  temporary  occlusion  of  both  common 
carotids  and  found  it  useful.  In  one  case  a  tape  passed  round  the  carotid 
and  secured  by  a  clamp,  pressed  against  the  internal  jugular  vein  and  caused 
much  venous  oozing  during  the  operation.  Abbe's  operation  has  given 
most  excellent  results,  and  seems  in  every  way  preferable  to  the  infinitely  more 
formidable  excision  of  the  ganglion. 

When  should  one  practise  excision  of  the  Gasserian  ganglion?  In 
cases  of  intolerable  tic  douloureux  one  should  try  the  milder  operations  of 
neurectomy,  as  their  death-rate  is  much  lower  than  that  of  the  major  operation; 
they  are,  in  fact,  safe  operations  and  good  permanent  results  are  sometimes 
obtained.  Furthermore,  the  neurectomies  give  at  least  temporary  relief,  and 
so  permit  the  strength  of  the  patients  to  be  built  up.  This  is  important,  as 
the  sufferers  from  tic  douloureux  are  often  much  reduced  from  their  long-con- 
tinued agony.  The  Abbe  operation  being  as  successful  as  the  Gasserian  gan- 
glion excision  and  not  very  much  more  dangerous  than  some  of  the  extracranial 
neurectomies,  ought,  in  many  aggravated  cases,  to  be  given  the  preference 
over  these. 


CHAPTER  V. 

PLASTIC  OPERATIONS  ON  THE  EXTERNAL  EAR. 

The  external  ear  when  very  large  or  very  projecting  may  be  operated  on 
for  cosmetic  reasons. 

Macrotia. — The  pinna  is  uniformly  enlarged  but  does  not  project  out- 


wards unnaturally.  Make  the  incision  AB  (Fig.  53)  through  the  whole  thick- 
ness of  the  pinna.  Pull  the  upper  segment  of  pinna  over  the  lower  segment 
to  see  how  much  tissue  must  be  removed  in  order  to  correct  the  deformity 


Fig.  56 


(Fig.  54).  Make  a  cut  from  D  to  B  and  remove  the  overlapping  triangle 
of  tissue  DBC.  The  edge  of  the  pinna  at  D  does  not  correspond  with  the 
edge  of  the  pinna  at  A,  therefore  cut  away  a  wedge-shaped  segment  of  pinna 

73 


74 


EXTERNAL   EAR. 


DEB  (Fig.  55)  and  so  permit  the  point  D  to  be  brought  out  to  the  point  A. 
With  sutures  introduced  alternately  from  the  outer  and  inner  side  of  the  ear, 
unite  the  edge  DEB  to  the  edge  AB.  Instead  of  lengthening  the  wound  edge 
DB,  it  might  be  possible  to  shorten  the  edge  AB  by  cutting  out  the  wedge 
of  tissue  XYZ,  (Fig.  55). 

(A)  Plastic  Restoration  of  Lobule. — The  lobule  of  the  ear  may  be 
absent  congenitally  or  may  have  been  removed  by  accident  or  for  disease.  If 
removed  for  disease  it  may  be  replaced  at  the  primary  operation  or  later. 

Gavello's  Operation. — Step  i. — ^Freshen  the  stump  of  the  lobule.  Apply 
pressure  with  a  hot  pad  to  stop  bleeding.     Retract  the  stump  upwards. 

Step  2. — Reflect,  and  fold  on  itself  the  flap  ABC  (Fig.  56).  With  sutures 
keep  the  two  raw  surfaces  of  the  flap  together. 


Fig.  57. — (Laurens.) 


Fig.  58. —  (Laurens.)  Fig.  59. — (Laurens.) 


The  flap  or  new  lobule  must  be  one-third  larger  than  the  normal  lobule; 
this  to  allow  for  shrinkage. 

Step  3. — Suture  the  upper  edge  of  the  new  lobule  to  the  vivified  stump  of 
the  old  lobule. 

Step  4. — Close  the  wound  in  the  neck  either  by  sliding  of  skin  or  by  grafts. 

(B)  Coloboma  of  Lobule. — A  part  of  the  lobule  may  be  absent  either 
congenitally  or  as  the  result  of  accident,  usually  the  result  of  necrosis  follow- 
ing piercing  of  the  lobule  with  dirty  instruments.  Nelaton's  method  of  op- 
erating will  be  easily  understood  by  glancing  at  Figs.  57,  58,  59. 


SYNECHIA  OF  LOBULE. 

Occasionally,  instead  of  hanging  in  the  normal  fashion  the  lobule  is  ad- 
herent to  the  body  through  its  whole  length.  The  deformity  may  be  annoy- 
ing. The  following  method  is  suggested  for  correction  of  the  synechia:  Mark 
the  line  along  which  the  lobule  ought  to  be  separated.     In  front  of  the  ear 


EXTERNAL    EAR. 


75 


raise  the  flap  X  (Fig.  60),  having  its  base  corresponding  to  the  above-mentioned 
line  and  attached  to  the  ear.  Behind  the  ear  elevate  the  flap  Y,  having  its 
base  or  pedicle  attached  to  the  neck  (Fig.  61).  Divide  the  lobule  along  the 
line  AB.  Attend  to  Hemostasis.  With  the  flap  X  cover  the  wound  now- 
existing  on  the  new  inner  edge  of  the  lobule.  With  the  flap  Y  cover  the  cor- 
responding wound  in  the  neck.     Fix  the  flaps  in  position  with  sutures. 


Fig.  60. 


Fig.  62. — {Laurens.) 


Fig.  62,.— {Laurens.) 


PROMINENT  EARS. 

Instead  of  lying  parallel  to  the  head  the  auricles  may  stand  out  more  or 
less  at  right  angles  to  the  head.  The  deformity,  especially  when  the  ears 
are  large,  is  considerable  and  may  have  an  injurious  influence  on  the  patient's 
career.     There  are  several  methods  of  correcting  the  deformity. 


76 


EXTERNAL   EAR. 


Fig.  64. — {Payr.) 


Fig.  65. — (Payer.) 


^: 


eC' 


IT.    X 


Fig.  66.— {Payr.) 


Fig.  67. — {Payr.) 


EXTERNAL   EAR. 


77 


\     V 


y 


Fig.  68.— (Pa>r.) 


Fig.  69. — -{Payr.) 


Fig.  70. — {Payr.) 


78 


EXTERNAL   EAR. 


Method  A. — The  deformity  is  not  of  high  degree.  There  is  little  or  no 
macrotia,  there  may  be,  as  in  Bacon's  case,  some  microtia.  Remove  the  whole 
thickness  of  the  skin  from  the  area  abed  (Fig.  62).  Take  away  more  skin 
from  the  auricle  than  from  the  mastoid  region.  Suture  the  edge  adb  to  the 
edge  acb  (Fig.  63). 

Method  B. — A  portion  of  the  skin  and  an  ellipse  of  cartilage  may  be  removed 
(Fig.  64),  and  the  wound  closed  (Fig.  65).  The  result  is,  however,  not  satis- 
factory. Payr  recommends  the  excision  of  a  sickle-shaped  portion  of  cartilage 
(Fig.  66).     This  gives  better  results. 

Method  C  (Payr's  Operation). — Payr  found  ("Archiv  fiir  klin.  Chir.," 
Ixxviii,  918)  that  the  results  from  Method  A  were  good  at  first  but  that  the 
spring-like  action  of  the  cartilage  of  the  ear  caused  stretching  of  the  scar  and 


Fig.  71. — I.  Helix.     2.  Antihelix.     3.  Fosba  of  helix.     4.  Fossa  of  antihelix. 


some  recurrence  of  the  deformity.  In  cases  of  great  deformity  he  operates 
as  follows: 

Step  I. — Remove  the  skin  from  the  areas  I  and  II  (Fig.  67).  Make  the 
incisions  a-a,  b-b,  c-c,  down  to,  but  not  into,  the  cartilage.  Reflect  the  flaps 
aabb  and  aacc. 

Step  2. — From  the  most  prominent  part  of  the  concha  posteriorly  make 
two  parallel  incisions  about  3/8  inch  apart,  through  the  cartilage  out  to  the 
free  margin  of  the  auricle.  Do  not  injure  the  skin  covering  the  anterior  sur- 
face of  the  cartilage.  Elevate  and  turn  back  the  flap  of  cartilage  (Fig.  68). 
From  the  cartilage  above  and  below  the  transverse  wound  remove  sickle- 
shaped  portions  of  cartilage  (Fig.  68). 

Step  3. — With  sutures  close  the  wounds  in  the  cartilage  (Fig.  69). 

Step  4. — In  a  convenient  location  make  two  parallel  incisions  through  the 
mastoid  periosteum  and  elevate  a  bridge  of  periosteum.  Pull  the  flap  of 
cartilage  vmder  the  periosteal  bridge  and  suture  it  there  (Figs.  69  and  70). 


RICKETT  S    OPERATION. 


79 


Step  5. — Close  the  wounds  aa,  bb,  cc  with  sutures  (Figs.  67  and  70).  Unite 
the  edges  of  the  denuded  area  I  to  the  edges  of  the  denuded  area  II  (Figs. 
67  and  70).  This  operation  corrects  both  the  macrotia  and  the  malposition. 
If  the  ear  is  not  much  enlarged  and  there  is  marked  malposition  the  anchoring 
flap  of  cartilage  may  be  made  narrow  and  the  sickle-shaped  resection  of  cartilage 
may  be  omitted. 

Method  D. — Ricketts  ("Surg.  Gyn.  Obst.,"  June,  1910)  considers  that 
in  prominent  ears  the  deformity  is  due  to  absence  or  insufficient  develop- 
ment of  the  antihelix  (Fig.  71),  the  cavity  of  the  concha  being  continuous 
with  that  of  the  helix.     To  form  an  antihelix  Rickett  operates  as  follows: 


Fig.  72. — {Ricketts,  Surg.  Gyn.  Obstet. 


Step  I. — On  the  inner  or  posterior  surface  of  the  auricle  make  a  crescentic 
incision  through  the  integument  opposite  the  line  of  the  intended  new  anti- 
helix. Remove  the  inscribed  integument.  Dissect  the  edges  of  the  skin  free 
from  the  cartilage  and  retract  them.  Remove  a  similar  crescentic  segment 
from  the  cartilage.  The  amount  of  cartilage  removed  depends  on  the  extent 
of  the  deformity.  Do  not  buttonhole  the  skin  on  the  anterior  or  external  side 
of  the  ear  when  removing  the  cartilage. 

Step  2. — Close  the  wound  in  the  cartilage  by  Lembert  sutures  so  as  to 
invert  the  edges  (Fig.  72)  and  form  an  antihelix. 

Step  3. — Close  the  skin  wound  with  horse-hair  sutures. 


CHAPTER  VI. 
EMPYEMA  OF  THE  ANTRUM  OF  HIGHMORE. 

INTRANASAL  OPERATION. 

Cocainize  the  lower  meatus  of  the  nose.  Seat  the  patient  with  his  head 
well  thrown  back.  Introduce  a  stout,  curved  trocar  and  cannula  through  the 
nostril  to  a  point  immediately  under  the  inferior  turbinated  bone,  i.  e.,  to  a 
point  in  the  highest  portion  of  the  inferior  meatus  of  the  nose.  Before  this 
can  be  done  it  may  be  necessary  to  remove  part  of  the  inferior  turbinate  bone. 
Turn  the  trocar  so  that  its  point  touches  the  outer  wall  of  the  nose  (inner  wall 
of  the  antrum)  at  right  angles.  Push,  with  steady  force,  outwards  so  as  to 
make  the  trocar  enter  the  antrum.  Wash  out  the  antrum  with  warm  water 
or  a  mild  antiseptic.  Do  not  use  peroxide  of  hydrogen;  it  may  spread  infection. 
Remove  the  trocar.  No  dressings  are  required.  The  trocar  used  ought 
to  be  large  enough  to  leave  a  more  or  less  permanent  opening. 

Alveolar  Route. — Provide  a  drill  about  the  size  of  a  No.  i6  French  sound. 
Provide  one  or  more  metal  drainage  tubes  about  3/4  to  i  inch  long,  provided 
with  a  flange  to  prevent  their  slipping  into  the  antrum.  Provide  a  nozzle 
which  can  slip  into  the  drain  and  permit  of  irrigation. 

Examine  the  teeth.  If  a  carious  tooth  is  found  it  is  probably  the  cause 
of  the  empyema,  and  must  be  extracted.  (The  teeth  at  fault  may  be  the  first 
premolar  or  the  first  or  second  molars.)  Through  the  tooth  socket  drill  a 
hole  upwards  and  backwards  (never  inwards)  into  the  antrum.  Remove 
the  drill,  substituting  a  drainage  tube.     Irrigate  daily  through  the  tube. 

Never  sacrifice  a  healthy  tooth  to  gain  access  to  the  antrum  by  this  route. 
The  drainage  tube  used  ought  to  fit  the  drill  hole  snugly  and  so  have  no  tendency 
to  fall  out. 

Radical  Operation. — This  method  is  based  on  the  obsolete  method  of 
drainage  through  the  canine  fossa.     Administer  a  general  anesthetic. 

Step  I. — Retract  the  upper  lip  upwards  and  outwards.  Make  an  incision 
to  the  bone  from  the  maxillary  tuberosity  to  a  point  immediately  below  the 
nares,  high  up  above  the  line  of  the  reflection  of  the  mucosa  from  the  alveolus 
to  the  cheek.  Attend  to  hemostasis  by  temporary  pressure.  Pull  the  upper 
edge  of  the  wound  upwards  with  a  retractor. 

Step  2. — With  a  periosteal  elevator  expose  the  whole  outer  wall  of  the  antrum. 
Do  not  injure  the  infraorbital  nerve.  Open  the  antrum  with  a  chisel,  enlarge 
the  opening  with  rongeur  forceps.  Cleanse  out  any  pus  and  blood  which 
may  be  present.     Attend  to  hemostasis  by  temporary  packing  with  gauze. 

Step  3. — Explore  the  antrum.     If  the  disease  is  catarrhal  merely  wash 

80 


EMPYEMA  ANTRUM.  8 1 

the  cavity.  If  granulation  tissue  is  present  in  quantity  remove  it  by  scraping 
it  away  with  pledgets  of  gauze  or  with  a  curette  used  gently.  If  necrosed 
bone  is  present  remove  sequestra  and  diseased  bone.  Occasionally  sinuses 
leading  through  the  alveolus  to  the  mouth  require  excision  (Laurens)  through 
a  vertical  cut  reaching  from  the  primary  incision  to  the  alveolar  margin.  Ex- 
amine the  inner  wall  of  the  sinus  carefully  behind  the  normal  opening  into 
the  nares,  because  ethmoidal  disease  may  cause  necrosis  here,  and  unless 
the  ethmoid  trouble  is  treated  a  cure  may  be  prevented. 

Step  4. — ^Provide  permanent  drainage  for  the  sinus  as  follows: 

With  chisel,  forceps,  etc.,  remove  the  lower  2/3  of  the  nasal  wall  of  the 
smus.  This  means  removing  the  lower  turbinate  bone  as  well.  Bleeding 
will  be  free  but  is  easily  stopped  by  gauze  pressure.  Be  sure  that  no  crest 
of  bone  remains  between  the  nasal  and  antral  floors  (Laurens).  Pack  the 
cavity  with  gauze  brought  out  through  the  nostril. 

Step  5. — Close  the  wound  in  the  mouth  with  sutures. 

Remove  the  pack  in  twenty-four  or  forty-eight  hours.  .After  this  keep  the 
parts  as  clean  as  possible  without  greatly  disturbing  the  patient. 

P.  L.  Friedrich's  Radical  Operation. — Make  an  incision  down  to  the 
bone,  skirting  the  ala  of  the  nose  in  the  natural  groove  of  this  region.  Expose 
the  outer  and  lower  angle  of  the  pyriform  opening.  With  the  elevator  separate 
the  soft  parts  and  periosteum  together  from  the  outer  surface  of  the  superior 
maxilla;  it  may  be  necessary  to  make  an  incision  to  the  bone  from  the  middle 
of  the  primary  incision  downwards  and  outwards  for  about  three-fourths 
of  an  inch.  With  the  elevator  separate  the  muco-periosteum  of  the  outer 
wall  of  the  nose  from  the  edge  of  the  pyriform  opening  backwards  for  about 
one  inch.  A  fair  area  of  both  the  facial  and  nasal  walls  of  the  lowest  portion 
of  the  antrum  are  exposed  by  the  above  means.  With  chisel  and  rongeurs, 
beginning  at  the  lower  and  outer  angle  of  the  pyriform  opening,  cut  away  the 
bony  walls  (both  facial  and  nasal)  of  the  antrum.  In  doing  this,  pan  of  the 
inferior  turbinate  bone  is  removed. 

Friedrich's  operation  gives  very  free  access  to  the  antrum  and  permits 
proper  treatment  both  of  the  antrum  and  of  any  fistulae  leading  from  it. 

The  intranasal  and  alveolar  methods  of  treating  empyema  of  the  antrum 
are  suitable  in  cases  of  catarrhal  inflammation,  or  where  dental  disease  is  the 
primary  cause  of  the  trouble.  When  the  disease  resists  drainage  for  two  or 
three  weeks  the  probabilities  are  that  osteitis,  necrosis  or  some  granulomatous 
condition  is  present  and  only  the  radical  operation  will  avail. 


CHAPSER  VII. 
OSTEOPLASTIC  EXPOSURE  OF  THE  ORBIT. 

Frankes'  Modification  of  Kronlein's  Operation. — This  operation  is 
of  value  in  the  exploration  of,  and  removal  of  tumors  from,  the  orbit  when 
it  seems  possible  to  preserve  the  eye. 

Step  I. — Below  the  level  of  the  eyebrow  make  an  incision  corresponding 
to  the  external  half  of  the  upper  margin  of  the  orbit.  Continue  the  incision 
downwards  along  the  outer  margin  of  the  orbit  to  a  point  near  the  lower  or- 
bital margin.  From  this  point  cut  backwards  on  the  malar  to  the  middle 
third  of  the  zygoma. 


Fig.  73. — Osteoplastic  Exposure  of  the  Orbit. 


Step  2. — (a)  Subperiosteally  divide  the  zygoma  near  its  middle,  {h) 
Beginning  at  the  upper  and  outer  part  of  the  orbital  rim,  subperiosteally  divide 
the  outer  orbital  rim  backwards  and  downwards  to  the  inferior  orbital  fissure 
(Fig.  73).  This  is  best  done  with  a  chisel,  (c)  Beginning  at  the  lower  and 
outer  part  of  the  orbital  rim,  subperiosteally  divide  the  malar  backwards  to 
the  inferior  orbital  fissure  and  to  the  origin  of  the  masseter. 

Step  3. — Reflect  the  bone  flap  thus  formed.  Remove  any  portions  of  the 
external  orbital  plate  which  obstruct,  and  so  expose  the  orbital  fat. 

Step  4. — Do  whatever  may  be  necessary  to  the  orbital  contents. 

Step  5. — Replace  the  bone  flap.  Suture  the  skin.  Suture  of  the  bone  is 
unnecessary. 

82 


CHAPTER  VIII. 


EXCISION  OF  UPPER  JAW. 


Many  incisions  have  been  devised  to  expose  the  superior  maxilla.  Prob- 
ably the  best  are  those  of  Weber  (A,  B,  C,  D,  Fig.  74)  and  Velpeau  (V,  P, 
Fig.  74). 

Weber's  Incision. — Beginning  immediately  below  the  inner  angle  of  the 
eye,  make  the  incision  B,  C,  D,  which  skirts  the  ala  of  the  nose  and  divides 
the  upper  lip  in  the  middle  line.  From  the  point  B  (Fig.  74)  make  the  curved 
incision  (B,  A,  Fig.  74)  which  follows  the  lower  margin  of  the  orbit.  Reflect 
outwards  the  flap  outlined  by  the  complete  incision. 

Velpeau's  Incision. — This  incision  is  very  similar  to  that  of  Syme.  Be- 
ginning at  the  angle  of  the  mouth,  make  the  incision,  P  V  (Fig.  74),  through  the 
whole  thickness  of  the  cheek.  The  cut  runs  obliquely 
upwards  and  outwards  from  the  angle  of  the  mouth 
for  such  a  distance  as  will  permit  of  exposure  of  the 
superior  maxilla  by  reflection  of  the  cheek  upwards  and 
inwards.     This  incision  is  not  so  good  as  Weber's. 

Separate  the  periosteum  covering  the  floor  of  the 
orbit  from  the  bone.  Gently  lift  the  orbital  contents 
upwards  with  a  flat  retractor.  With  a  bone  forceps  or 
Gigli  saw  divide  the  malar  bone  and  with  it  part  of 
the  orbital  floor  at  the  point  V  (Fig.  75).  In  the  same 
manner  divide  the  nasal  and  orbital  processes  of  the 
superior  maxilla  at  the  point  X.  Open  the  patient's 
mouth  and  with  a  knife  make  an  incision  through  the 

muco-periosteum  of  the  hard  palate,  parallel  and  close  to  the  middle  line. 
Continue  this  incision  forwards  and  then  upwards  through  the  muco-perios- 
teum covering  the  alveolus  to  the  nasal  aperture.  With  bone  forceps,  Gigli  or 
finger  saw  divide  the  hard  palate  and  alveolus  along  the  line  of  the  muco- 
periosteal  incision.  With  knife,  or  better  with  scissors,  separate  the  soft 
palate  from  the  hard  palate  on  the  side  being  excised.  Seize  the  superior 
maxilla  with  lion-jawed  forceps  and  forcibly  remove  it  with  a  twisting  motion. 
Any  undivided  strands  of  tissue  may  be  severed  with  scissors.  The  internal 
maxillary  artery  will  generally  be  found  bleeding  vigorously  in  the  depth  of 
the  wound.  It  should  be  seized  with  forceps  and  ligated.  Oozing  is  stopped 
by  pressure  with  gauze  pads  wrung  out  of  very  hot  water.  Pack  the  wound 
with  iodoform  gauze.  Replace  the  flap  of  soft  structures  over  the  packing 
and  suture  it  in  position. 

83 


84 


EXCISION    UPPER   JAW. 


The  after-treatment  consists  in  having  the  patient  lie  on  the  side  operated 
upon  or  sit  up  in  bed  or  a  chair  as  early  as  possible.  This  is  to  avoid  danger 
of  pneumonia.  The  mouth  must  be  kept  clean.  Closure  of  the  wound  usually 
takes  place  rapidly.  When  recovery  has  taken  place,  consult  a  good  dentist 
with  regard  to  the  use  of  an  artificial  palate. 

Keen  notes  that  sarcoma  of  the  upper  jaw  often  extends  through  the  in- 
fundibulum  into  the  frontal  sinus.  This  extension  must  be  looked  for  and 
removed.     Extend  the  incision  C,  B  (Fig.  74)  upwards  to  the  nasal  side  of  the 

inner  canthus  over  the  frontal  sinus. 
Remove  vdth  a  small  rongeur  the  an- 
terior wall  of  the  infundibulum  and  of 
the  frontal  sinus;  wipe  away  the  tongue- 
shaped  process  of  the  sarcoma  with  a 
gauze  pad. 

W.  J.  Hearn,  Matas,  and  others 
always  ligate  the  external  carotid  before 
excising  the  jaw.  The  former  surgeon 
finds  in  doing  so  that  he  always  exposes 
some  enlarged  glands  which  require  re- 
moval. Matas  emphasizes  the  import- 
ance of  ligating  the  external  carotid  high 
up,  well  above  the  bifurcation,  otherwise 
there  is  danger  from  cerebral  embolism. 
A.  H.  Ferguson's  operation,  suitable 
in  cases  where  the  skin  is  not  involved. 

1.  Place  the  patient  with  head  hang- 
ing over  a  sand-bag. 

2.  Make  an  incision  about  one-half 
inch  long  over  the  nasal  process  of  the  superior  maxilla;  through  this,  with  an 
osteotome,  divide  the  bony  process. 

3.  Repeat  Step  2  over  the  junction  of  the  superior  maxilla  and  the  malar 
and  divide  the  bone. 

4.  Cut  through  the  alveolar  process  and  the  hard  palate.  Save  as  much 
of  the  soft  palate  as  possible. 

5.  With  elevator  or  forceps  evulse  the  jaw  and  pull  it  out  through  the 
mouth.     Pack  the  cavity  with  iodoform  gauze. 


Fig.  75. — Excision  of  Upper  Jaw. 
X,IY,  Z.  Usual  lines  for  division  of  bone. 
P,  Q.  Section  may  be  made  here  instead  of 
at  Z,  when  disease  is  extensive. 


BARDENHEUER'S  OPERATION  FOR  PARTIAL  EXCISION  OF  THE 
UPPER  JAW  AND  IMMEDIATE  PLASTIC  REPAIR. 

By  means  of  the  incision  A,  B,  C  (Fig.  76)  the  flap  C,  E,  D  is  reflected 
and  the  jaw  and  tumor  exposed.  By  means  of  saw,  bone  forceps,  and  scissors 
the  jaw  is  partially  excised,  the  object  being  to  remove  the  tumor  and  with 
it  a  safe  margin  of  healthy  bone.     Bleeding  is  arrested  by  ligature,  hot  water. 


UPPER   JAW. 


85 


and  sponge  pressure.  The  incision  F,  G,  H  (Fig.  77)  outlines  a  skin-flap 
(hairless)  in  the  pedicle  of  which  is  a  portion  of  the  skin  of  the  upper  eyelid 
as  well  as  the  whole  eyebrow.  The  flap  is  turned  (epidermis  inwards)  into 
the  position  F,  I,  H,  and  there  sutured.  The  flap  C,  E,  D  is  now  turned  back 
into  its  old  position  and  there  sutured.  Most  of  the  wound  F,  G,  H  is  covered 
by  Thiersch's  grafts.  After  the  lapse  of  two  weeks  the  pedicle  of  the  flap 
F,  H,  I  is  divided  and  the  eyelid  and  eyebrow  contained  in  it  returned  to  their 
normal  position.  The  wound  left  where  the  pedicle  was  divided  must  be 
trimmed  and  closed.     The  result  is  seen  in  Fig.  78. 


Fig.  76. — {After  Bardenheuer.) 


Fig.  77. — {After  Bardenheuer.) 


EXCISION  OF  SUPERIOR  MAXILLA  WHERE  THERE  IS  TUMOR 
INVOLVING  BOTH  THE  BONE  AND  THE  SKIN. 

Make  the  incision  A,  B,  C  (Fig.  79).  Isolate  the  tumor  from  the  rest  of 
the  skin  by  the  incision  D,  F,  E,  which  joins  A,  B  and  B,  C  at  the  points  D 
and  E.  Reflect  the  flap  A,  D,  E,  C  towards  the  opposite  side  of  the  body 
(Fig.  80).  Reflect  the  skin  at  B  towards  the  ear  so  as  to  expose  the  zygoma 
and  the  frontal  process  of  the  malar.  Divide  the  bones  as  shown  in  the  dotted 
lines  in  Fig.  77.  Remove  the  tumor  and  superior  maxilla  as  in  the  classical 
operation  for  excision  of  the  upper  jaw.  Pack  the  wound  with  iodoform 
gauze.     Replace  the  flaps  and  suture  them  in  position. 


EXTENSIVE  EXCISION  OF  UPPER  JAW. 

The  younger  Konig  in  very  extensive  disease  of  the  upper  jaw  necessitating 
removal  of  the  floor  and  outer  wall  of  the  orbit  recommends  the  following 
operation: 

1.  Ligate  the  external  carotid  between  the  origin  of  the  superior  thyroid 
and  lingual  arteries.     This  step  is  simple,  harmless,  and  very  useful. 

2.  Expose   the   bone   by   Velpeau's   incision.     Remove   the   disease. 


86 


EXCISION   UPPER   JAW. 


3.  Recognize  and  expose  the  temporal  muscle  in  the  outer  part  of  the 
wound.  At  the  level  of  the  coronoid  process  and  about  i  1/2  finger-breadths 
from  its  anterior  margin  split  the  muscle  upwards  and  downwards.  With 
a  chisel  divide  the  ascending  ramus  of  the  lower  jaw  along  the  line  in  which 


Fig.  78. — {After  Bardenheuer.) 


Fig.  79. 


the  muscle  was  split.  The  result  of  the  above  is  to  provide  a  flap,  consisting 
of  temporal  muscle  and  bone,  attached  above  to  the  skull  and  free  below 
(Fig.  81). 

4.  Turn  this  flap  inwards  and  unite  its  free  extremity  to  the  remains  of 


Fig.  80. 


the  frontal  process,  so  that  a  firm  floor  is  provided  for  the  orbit  and  the  eye 
is  kept  in  place. 

5.  Complete  the  operation  by  closure  of  the  skin- wound  and  packing  with 
iodoform   gauze. 


UPPER   JAW. 

RODENT  ULCER. 


87 


As  a  type  of  operation  for  rodent  ulcer  an  example  may  be  taken  where 
the  disease  involves  the  malar,  the  superior  maxilla,  and  to  a  moderate  extent 
the  orbit. 

I.  Make  an  incision  around  the  disease,  and  distant  from  it  1/2  inch 
(Fig.  82). 


Fig.  81. 


Fig.  82. 


2.  Leaving  the  diseased  tissue  undisturbed,  reflect  the  soft  parts  all  around 
it  from  the  bones  so  as  to  lay  bare  to  touch  the  upper  margin  of  the  orbit, 
the  external  angular  process  of  the  frontal  bone,  the  temporal  process  of  the 
malar  (Fig.  83),  the  external  anterior  surface  of  the  superior  maxilla  above 


Fig.  83. 

the  alveolar  process,  and  the  nasal  bone  on  the  affected  side.     As  hemorrhage 
occurs,  it  must  be  arrested  at  once. 

3.  With  bone  forceps  or  chisel  cut  through  the  bones  as  shown  in  Fig.  84. 
Bone  incision  A  (Fig.  84)  penetrates  the  antrum  of  Highmore. 

4.  Separate  the  orbital  contents  from  the  roof  of  the  orbit  and  divide  the 
optic  nerve. 


88 


EXCISION   UPPER  JAW. 


It  is  now  easy  to  remove  the  disease  surrounded  by  a  fairly  large  zone 
of  healthy  tissue.  The  cavity  is  packed  with  iodoform  gauze.  After  the 
lapse  of  about  ten  days  endeavors  may  be  made  to  lessen  the  deformity  which 
has  been  produced.  As  the  cavity  is  largely  lined  by  mucous  membrane, 
it  is  proper  that  an  endeavor  should  be  made  to  provide  its  new  covering  with 
an  epidermal  surface  internally. 

Type  of  Operation  to  Repair  the  Deformity. — On  the  hairless  forehead 
make  the  incision  A,  B,  C,  Fig.  85,  so  as  to  obtain  a  flap,  A,  C,  D,  of  size 
and  shape  suitable  to  provide  an  epidermal  outer  and  anterior  wall  to  the 
cavity  left  by  operation.  The  base  (A,  C)  of  the  flap  is  a  little  above  the  orbit 
and  ought  to  extend  beyond  the  orbit  on  one  side  or  the  other  so  as  to  have 


Fig.  84.  Fig.  85. 

plenty  of  nourishment.  The  flap  is  now  turned  down  so  that  its  epidermal 
surface  faces  inwards,  its  raw  surface  outwards.  The  edges  of  the  flap  are 
stitched  with  catgut  in  the  position  A,  C,  D  (Fig.  85).  From  the  neck  the 
flap  E,  F,  G  is  dissected  up  and  sutured  in  the  position  F,  E,  H,  I.  The 
raw  surfaces  A,  B,  C  and  E,  F,  G  are  lessened  in  size  by  sliding  their  edges 
centripetally  and  there  suturing  them.  Any  parts  not  covered  by  skin  are 
now  grafted  by  Thiersch's  method. 

After  the  lapse  of  two  weeks,  if  everything  has  gone  well,  the  pedicles  of 
the  flaps  A,  D,  C  and  H,  I,  E  are  divided  and  their  remnants  turned  back 
into  their  old  positions.  A  certain  amount  of  trimming  and  suturing  must  be 
done  at  the  margins  of  the  now  repaired  deformity. 

Note. — In  the  original  operation  when  the  bone  incisions  are  being  made  it  is 
wise  to  divide  the  nasal  bones  last,  so  as  to  avoid  the  entrance  of  blood  into  the  nose. 
The  complete  dissection  of  the  soft  parts  before  attacking  the  bones  ensures  that  most 


UPPER   JAW.  89 

of  the  bleeding  will  have  been  attended  to  before  any  of  the  facial  cavities  have  been 
opened.  Should  the  patient's  strength  warrant,  the  reparative  work  might  be  done 
at  the  same  sitting,  but  the  disease  generally  affects  the  old  and  debilitated. 

Osteoplastic  Resection  of  Upper  Jaw  (Kocher). — Suitable  for  the  re- 
moval of  nasopharyngeal  and  retropharyngeal  neoplasms — e.  g.,  sarcomata,  etc. 

Preliminary  ligation  of  both  external  carotid  arteries  may  or  may  not  be 
practised.  Place  the  patient  in  Trendelenburg's  position.  This  renders 
preliminary  tracheotomy  unnecessary. 

Step  I. — Split  the  upper  lip  near  the  middle  line  from  nostril  to  mouth. 
On  each  side  divide  the  buccal  mucosa  at  its  line  of  reflection  from  cheek 
to  alveolus.  Only  di\dde  the  mucosa  sufl&ciently  to  permit  the  performance 
of  Step  2. 

Step  2. — With  a  chisel  divide  the  anterior-external  wall  of  the  antrum  from 
the  nose  outwards  and  backw^ards  above  the  alveolus.     This  opens  the  antrum. 

Step  3. — With  a  wide  chisel  (better  osteotome)  of  thin  steel  divide  the 
alveolus  and  hard  palate  close  to  the  middle  line.  With  strong  sharp  hooks 
pull  the  halves  of  the  upper  jaw  apart,  pushing  the  vomer  to  one  side  and 
dividing  any  nasal  mucosa  which  hinders.  If  necessary  divide  the  soft  palate. 
Remove  any  of  the  turbinated  bones  which  obstruct. 

Step  4. — Free  access  to  the  base  of  the  skull  is  now  possible.  Remove 
the  tumor  secundem  artem,  using  the  cautery  if  necessary. 

Step  5. — Replace  the  halves  of  the  jaw  and  fix  them  by  a  suture  (wire  or 
silk)  penetrating  the  alveolus.     Suture  the  soft  palate  if  it  has  been  divided. 

Step  6. — Apply  iodoform  gauze  packs  to  the  bed  from  which  the  tumor 
w^as  removed  bringing  the  ends  of  the  pack  out  through  the  nose, 

Reinhardt  ("  Zentralblatt  flir  Chir.,"  May  9,  1908)  has  collected  fourteen 
cases  in  which  this  operation  has  been  performed  without  a  death. 

Exposure  of  the  Base  of  Skull  by  Temporary  Resection  of  the  Palate. — C. 
Hofmann's  method  ("Zentralblatt  flir  Chir.,"  1910,  No.  24). 

Step  I. — Make  an  incision  through  the  mucosa  of  the  palate  from  the 
premolar  tooth  on  the  right  side  to  a  corresponding  point  on  the  left  side. 
Nearly  at  right  angles  to  the  above  incision  make  a  cut  immediately  to  the 
inner  side  of  the  alveolus  (on  the  right  or  left  side  of  the  palate,  according 
to  the  location  of  the  tumor  in  the  nasopharynx).  This  incision  extends 
backwards  to  the  edge  of  the  soft  palate  dividing  the  muco-periosteum  cover- 
ing the  hard  palate  and  the  whole  thickness  of  the  soft  palate. 

Step  2. — With  a  chisel  divide  the  bone  of  the  palate  corresponding  to  the 
incision  made  in  Step  i.  With  an  elevator  raise  the  palate  and  reflect  the 
flap  of  bone  and  soft  parts,  fracturing  the  bone  in  the  pedicle  of  the  flap. 
WTiile  this  is  being  done  the  nasal  septum  must  necessarily  be  either  fractured 
or    divided. 

Step  3. — After  removal  of  the  tumor  from  the  nasopharynx  replace  the 
flap  and  fix  it  with  a  few  sutures.  Hofmann  states  that  the  flap  tends  to  stay 
in  position  and  that  the  whole  operation  is  easy. 


CHAPTER  IX. 


LOWER  JAW.     RESECTION. 


I.  RESECTION  OF  THE  ALVEOLAR  PROCESS. 

Incise  the  muco-periosteum  around  the  portion  of  bone  to  be  excised.  If 
the  portion  to  be  excised  is  small,  its  removal  may  be  effected  with  rongeur 
forceps  or  with  the  chisel  and  mallet.  In  using  the  chisel  the  surgeon  should 
hold  the  instrument  in  one  hand,  support  the  jaw  with  the  other,  and  let  his 
assistant  manipulate  the  mallet.  When  the  excision  is  to  be  more  extensive, 
one  may  with  a  finger  saw  make  a  vertical  incision  through  the  alveolar  process 
in  front  of,  and  another  behind,  the  portion  to  be  removed,  and  join  the  lower 
ends  of  the  vertical  incisions  by  a  horizontal  one  cut  with  a  chisel  or  a  saw 
operated   by   a   surgical    engine. 

II.  PARTIAL  RESECTION  OF  THE  HORIZONTAL  RAMUS. 

Make  an  incision  through  the  skin  down  to  the  bone  along  the  inferior 
edge  of  the  jaw.  Separate  the  soft  parts  from  the  inner  and  outer  surfaces 
of  the  jaw.     If  the  operation  is  done  for  necrosis,  preserve  the  periosteum; 

if  for  tumor,  sacrifice  it.  Divide  the  jaw 
by  vertical  incisions  made  with  the  Gigli 
wire  or  the  finger  saw,  in  front  of  and 
behind  the  disease.  If  teeth  are  present 
at  the  lines  of  vertical  incision,  they  must 
be  removed  before  the  saw  is  applied. 
Remove  the  segment  of  bone  between 
the  vertical  cuts.  Whenever  the  nature 
and  extent  of  the  disease  permit,  it  is 
important  to  leave  the  lower  edge  of  the 
jaw  in  situ  (X,  Y,  Fig.  86),  as  then  the 
continuity  of  the  maxilla  is  maintained. 
To  accomplish  this,  the  vertical  bone 
incisions  do  not  completely  divide  the  jaw,  and  the  excision  is  completed  with 
the  chisel.  If  possible,  suture  the  mucous  membrane  of  the  floor  of  the  mouth 
to  that  of  the  cheek.     Close  the  cutaneous  wound  after  providing  for  drainage. 


Fig.  80. 


III.   RESECTION   OF   ONE-HALF   OF  THE   INFERIOR  MAXILLA. 

Transfix  the  tongue  with  a  stout  thread  for  purposes  of  traction.     Make 
a  vertical  incision  in  the  middle  line  through  the  chin,  beginning  a  little  below 

90 


LOWER   JAW.  91 

the  edge  of  the  lower  lip  and  ending  on  the  lower  edge  of  the  jaw.  Do  not 
include  the  margin  of  the  lower  lip  in  the  cut  unless  compelled  to  do  so  by  the 
size  of  the  tumor. 

From  the  lower  end  of  the  vertical  incision  make  a  cut  along  the  inferior 
edge  of  the  jaw  to  its  angle.  If  necessary,  continue  the  cut  up  the  posterior 
edge  of  the  ascending  ramus  of  the  jaw  to  a  point  not  less  than  one  finger- 
breadth  below  the  lobe  of  the  ear.  Before  the  facial  artery  is  divided  it  should 
be  ligated. 

With  periosteal  elevators,  scissors,  and  knife  separate  the  soft  parts  from 
the  outer  side  of  the  bone  to  be  removed.  If  the  operation  is  for  the  removal 
of  a  tumor,  sacrifice  the  periosteum.  Choose  the  line  in  which  to  divide 
the  bone  anteriorly,  extract  any  teeth  which  may  be  in  the  way,  and  divide 
the  bone  with  the  Gigli  wire  or  finger  saw  after  the  soft  parts  have  been  sepa- 
rated from  both  sides  of  the  bone  along  the  line  of  section.  Pull  the  jaw  down- 
wards and  outwards  and  separate  the  soft  parts  from  its  inner  surface  (my- 
lohyoid, geniohyoid,  and  internal  pterygoid  muscles,  submaxillary  gland, 
etc.).  Pull  the  jaw  downwards,  expose  the  coronoid  process,  and  divide  its 
attachments  to  the  temporal  muscle.  It  may  save  time  and  be  easier  to  cut 
through  the  coronoid  process  with  bone  forceps  than  to  separate  the  tem- 
poral muscle  from  it. 

By  blunt  dissection  separate  the  masseter  muscle  and  the  parotid  gland 
from  the  ascending  ramus.  With  a  twisting  movement  directed  downwards 
and  outwards  tear  the  head  of  the  bone  out  of  its  bed  and  the  active  part  of 
the  operation  is  completed.  Attend  to  hemostasis.  If  possible,  suture  the 
mucous  membrane  of  the  floor  of  the  mouth  to  that  of  the  cheek.  Close 
the  external  wound  after  providing  for  drainage. 

The  after-treatment  consists  in  endeavoring  to  keep  the  mouth  clean 
by  means  of  frequent  washing  with  mild  antiseptic  solutions,  in  nourishing 
the  patient,  and  in  encouraging  him  to  sit  or  walk  about  at  as  early  a  date  as 
possible. 

After  any  of  the  operations  in  which  one-half  of  the  inferior  maxilla  or 
a  segment  of  it  is  removed,  deformity  results  and  the  teeth  of  the  lower  jaw 
no  longer  articulate  with  their  fellows  above.  Some  surgeons  or  dental  sur- 
geons have  managed  by  a  long  and  painful  process  to  push  the  fragments  of 
the  lower  jaw  back  into  their  normal  position  after  healing  has  taken  place 
and  have  maintained  the  position  by  means  of  a  plate  or  of  bridge-work. 

Sinclair  WTiite  ("Brit.  Med.  Journ.,"  Nov.  27,  1909),  in  removing  two 
inches  of  the  lower  jaw  for  a  tumor  preserved  the  periosteum  of  the  lower  edge 
of  the  excised  segment.  "The  resected  surfaces  of  the  lower  jaw  were  pierced 
with  a  drill  to  the  depth  of  3/4  inch.  The  drill  hole  in  the  body  was  hori- 
zontal and  placed  near  its  lower  margin,  so  as  to  miss  the  teeth  roots;  that 
in  the  ramus  was  vertical  and  somewhat  posterior  to  the  mandibular  fora- 
men. The  ends  of  a  suitable  length  of  stout  silver  wire  were  jammed  tightly 
into  the  drill  holes,   and  the  wire   completely  covered  by  suturing  together 


92  LOWER   JAW,    RESECTION. 

the  mucous  membranes  of  the  cheek  and  the  floor  of  the  mouth  over  it.  The 
diagram  (Fig.  87)  indicates  the  position  and  curve  of  the  vi^ire. 

A  small  drain  tube  was  placed  in  the  neck  end  of  the  wound  and  retained 
for  forty-eight  hours,  and  the  mouth  was  rinsed  frequently  with  hydrogen  per- 
oxide solution.  A  little  pus  formed  in  the  track  of  the  tube,  but  the  wound 
in  the  mouth  healed  quite  kindly. 

"  At  the  present  time,  except  for  the  skin  scar,  there  is  absolutely  no  ex- 
ternal deformity.  He  can  open  his  mouth  almost  to  the  full,  and  when  the 
jaws  are  closed  the  teeth  on  the  right  side  meet  accurately  those  in  the  cor- 
responding side  of  the  upper  jaw.  He  is  able  to  bite  soft  things,  and  has  to 
be  restrained  from  attempting  greater  masticatory  feats." 

Partsch,*  after  removing  a  segment  of  the  lower  jaw,  keeps  the  ends  of 
the  bone  in  correct  position  by  means  of  a  perforated  metal  plate  united  to 
the  bone  by  a  couple  of  wire  stitches.     (See  Fig.  88.)     The  metal  plates  are 


Fig.  87. — (Sinclair  While.) 

protected  with  rubber  tubing,  and  the  mucous  membrane  of  the  floor  of  the 
mouth  and  of  the  cheek  are  sutured  together  below  the  metal  plate  so  that 
the  latter  lies  exposed  in  the  oral  cavity.  As  soon  as  a  proper  dental  apparatus 
or  plate  can  be  made  and  properly  fitted,  the  temporary  metal  plates  are 
removed.  Berndt,  in  cases  where  half  the  inferior  maxilla  has  been  removed, 
replaces  it  with  an  apparatus  of  celluloid.  After  the  bone  has  been  removed 
he  sutures  the  mucous  membrane  of  the  floor  of  the  mouth  to  that  of  the 
cheek,  packs  the  wound,  and  lays  silkworm-gut  cutaneous  sutures  in  position 
but  does  not  tie  them.  After  the  lapse  of  about  ten  days  he  takes  a  celluloid 
ring  pessary,  softens  it  by  boiling,  moulds  it  to  the  proper  shape,  and  puts 
it  into  the  wound  so  that  one  end  is  in  the  glenoid  cavity  while  the  other  rests 
against  the  sawed  surface  of  the  remnant  of  the  lower  jaw.  He  next  closes 
the  skin-wound  and  ties  the  sutures  already  in  place,  thus  completely  cover- 
ing the  celluloid  apparatus.  Berndt  reports  that  slight  suppuration  often 
takes  place  anteriorly  from  irritation  to  the  sawed  surface  of  bone,  but  that 
if  a  small  portion  of  the  celluloid  is  then  cut  away  by  forceps,  a  little  fibrous 
tissue  forms  between  the  bone  and  the  foreign  body,  and  the  wound  heals. 
One  patient f  seven  months  after  operation  claimed  to  have  celebrated  Christ- 

*  "Archiv  f.  klin.  Chir.,"  Iv,  746. 
t  "Archiv  f.  klin.  Chir.,"  Ivi,  210. 


LOWER   JAW. 


93 


mas  by  cracking  nuts  with  his  jaw,  one-half  of  which  was  celluloid,  and  to 
have  suffered  no  ill  consequences. 

By  an  incision  made  through  the  skin  below  the  jaw  Macewen  has  im- 
planted a  piece  of  rib  between  the  fragments  of  jaw.  Of  course  no  com- 
munication existed  between  the  site  of  implantation  and  the  mouth.  The 
implanted  bone  was  obtained  from  a  rib  near  the  axilla.  The  result  was 
perfect. 

H.  Nimier*  gives  an  admirable  description  of  Martin's  prosthetic  appara- 
tus suitable  for  use  after  even  very  extensive  excision  of  the  inferior  maxilla. 
He  says:  Provided  with  a  segment  of  maxilla  formed  out  of  hard  rubber, 
moulded  in  advance  to  represent  the 
bone  to  be  excised,  the  surgeon  cuts  and 
fashions  it  so  as  to  fit  between  the  re- 
maining portions  of  the  bone  and  to  re- 
establish the  exact  shape  of  the  inferior 
maxilla.  Two  small  platinum  plates  at 
each  end  of  the  apparatus  are  attached 
to  the  bones  by  screws,  and,  acting  as 
fish-plates  between  the  bone  and  the 
substitute  for  bone,  keep'  the  latter  in 
position.  If  much  of  the  ascending 
ramus  has  been  removed,  the  anterior 
portion  of  the  apparatus  is  fixed  to  the 
renmants  of  the  coronoid  process,  while 
that  portion  corresponding  to  the  articu- 
lation is  left  unattached.  To  assure 
solidity  in  such  cases  it  is  necessary  to 
attach  the  apparatus  to  the  palate  by  a 
movilded  plate.  On  the  upper  edge  of  the  apparatus  a  band  of  hard  rubber 
roughly  simulates  the  teeth.  It  is  necessary  to  disinfect  the  tissues  in 
which  the  foreign  body  is  implanted,  and  for  this  purpose  the  apparatus 
is  perforated  in  various  directions,  so  that  irrigation  is  easy.  Fig.  89 
shows  apparatus  used  after  an  almost  complete  excision  of  the  lower  jaw. 
The  above  description  applies  to  the  implantation  of  a  temporary  splint. 
When  cicatrization  is  complete,  a  permanent  one  replaces  it.  The  perma- 
nent apparatus  is  merely  a  more  elaborate  edition  of  the  temporary.  In  cases 
of  extensive  excision  the  apparatus  may  be  introduced  in  two  parts,  which 
are  then  united  by  fish-plates  and  screws. 

Such  extremely  ingenious  and  complicated  prosthetic  devices  will  rarely 
be  available  when  required,  and  if  available,  must  rarely  be  serviceable. 
The  tissues  do  not  tolerate  foreign  bodies  well  for  any  length  of  time,  and 
especially  mobile  bodies,  such  as  described  above.  They  have  been  de- 
scribed here  more  as  examples  of  surgical  ingenuity  than  as  practical  aids. 

*  "Traite  de  Chir.,"  Delbet  and  Le  Dentu,  v,  793. 


Fig.  89. 
I.  Articular  process  lower  jaw.  2. 
Hard-rubber  ridge  representing  teeth. 
3.  Artificial  lower  jaw.  4.  Fish-plate 
uniting  remnants  of  bone  to  the  apparatus. 
5.  Fish-plate  uniting  the  two  halves  of 
the  apparatus,  c.  System  of  tubes  for 
irrigation. 


94  LOWER   JAW,    RESECTION. 

Undeveloped  Lower  Jaw. — When  there  is  marked  want  of  development 
of  the  lower  jaw  there  is  not  only  present  a  disfiguring  recession  of  the  chin 
but  the  patient  may  be  unable  to  open  the  mouth  more  than  one-eighth  of  an 
inch.  V.  P.  Blair  ("Journ.  A.  M.  A.,"  July  17,  1909),  has  twice  success- 
fully operated  as  follows: 

Step  I. — Make  an  incision  about  1/2  inch  in  length  in  front  of  the  lobe 
of  each  ear  and  retract  the  parotid  backwards. 

Step  2. — Pass  a  curved  needle  with  thread  through  the  incision,  under 
the  ramus  and  out  through  the  cheek.  By  means  of  the  thread  pull  a  Gigli 
saw  round  the  ramus  and  divide  the  bone  horizontally. 

Step   3. — Forcibly    stretch   the   muscles   of    mastication. 

Step  4. — ^Pull  the  body  of  the  jaw  forwards  if  possible  until  the  lower  in- 
cisors are  in  front  of  the  upper.  Wire  teeth  of  the  lower  jaw  to  teeth  of  the 
upper  until  sufficient  fixation  is  obtained. 

ANCHYLOSIS  OF  TEMPORO-MAXILLARY  JOINT. 

The  usual  procedure  for  the  operative  treatment  of  bony  anchylosis  of 
the  temporo-maxillary  joint  consists  in  mere  excision  of  the  condyle  of  the 
lower  jaw.  Helferich,  having  had  poor  results  from  the  above  operation, 
modified  it  slightly.  His  modification  is  founded  on  the  fact  that  interposi- 
tion of  the  muscle  between  the  fragments  is  a  common  cause  of  non-union  in 
fractures. 

Helferich's  Operation. — Make  a  vertical  incision  i  1/2  to  2  inches  in 
length,  one  finger  breadth  in  front  of  the  ear.  I.igate  the  temporal  artery. 
Push  the  parotid  gland  aside;  expose  the  condyle  and  neck  of  the  lower  jaw. 
The  temporo-maxillary  joint  may  be  indistinguishable  because  of  anchylosis. 
With  a  chisel  divide  the  neck  of  the  bone  at  a  point  about  1/2  inch  below 
the  site  of  the  joint.  Do  not  preserve  the  periosteum.  Excise  the  condyle 
and  neck  of  the  jaw  above  the  point  of  section,  taking  away  the  periosteum 
with  them.  If  only  one  joint  is  anchylosed,  the  mouth  can  now  be  easily 
opened.  If  necessary,  enlarge  the  skin-incision  upwards.  Reflect  a  long 
flap  from  the  temporal  muscle,  about  one  inch  wide  and  with  its  base  below. 
Turn  the  flap  downwards  so  that  its  free  end  can  be  tucked  into  the  defect 
left  by  the  excision  of  the  condyle.  To  turn  the  flap  down  and  put  it  in  po- 
sition requires  that  a  portion  of  the  zygomatic  arch  be  removed.  This  is  easily 
done  with  rongeur  or  bone  forceps.  Fix  the  muscular  flap  in  position 
by  a  few  sutures  of  catgut.  Close  the  wound  without  drainage.  Apply 
dressings.  The  result  obtained  from  Helferich's  operation  was  most  happy. 
Murphy's  experience  seems  to  show  that  a  flap  of  fat  is  preferable  to  muscle 
in  the  above  operation. 

L.  W.  Arlow*  finds  that  in  severe  cases  of  temporo-maxillary  anchylosis 
the  pathological  changes  are  by  no  means  limited  to  the  joint,  but  that  os- 
teitis alters  the  form,  size,  and  relations  of  the  articular  process,  the  coronoid 

*  Ref.  "Centralblatt  f.  Chir.,"  1903,  No.  28. 


LOWER   JAW. 


95 


process,  the  incisura  semilunaris,  the  zygoma,  etc.  As  a  consequence  simple 
division  of  the  articular  process  is  insufficient  to  give  motion,  and  even  when 
combined  with  osteotomy  of  the  coronoid  it  often  fails  and  resection  of  a 
part  of  the  full  width  of  the  upper  portion  of  the  ascending  ramus  becomes 
necessary.  Facial  paralysis  is  more  common  as  a  result  of  tearing  and  dis- 
traction than  of  accidental  division  with  knife  or  chisel.  Recurrence  is 
avoided  by  extensive  removal  of  bone,  by  the  implantation  between  the  frag- 
ments of  muscle  or  even  of  metal  plates,  and  by  early  passive  and  active 
motion.  Monod  and  Vanverts  strongly  recommend  osteotomy  of  the  ascend- 
ing ramus  as  being  easier  than  resection  of  the  neck  of  the  bone,  as  efficient, 
and  not  liable  to  cause  injury  to  the  facial  nerve.  Rochet's  method  of  op- 
erating is  as  follows: 


Fig.  90. — {After  Monod  and  Vanverts.) 


Fig.  91. — {After  Monod  and  Vanverts.) 


Step  I. — Make  an  incision  bordering  the  angle  of  the  jaw.  About  one 
inch  of  this  incision  runs  along  the  lower  edge  of  the  horizontal  ramus,  and 
about  one  inch  along  the  posterior  edge  of  the  ascending  ramus.  Through 
this  expose  the  inferior  insertion  of  the  masseter  and  detach  it  from  below 
upwards  with  an  elevator.  This  exposes  the  outer  surface  of  the  bone.  In 
the  same  way  expose  the  inner  surface  of  the  bone  by  separating  the  inser- 
tion of  the  internal  pterygoid. 

Step  2. — With  chisel,  forceps,  or  Gigli  saw  divide  the  bone  along  the  lines 
marked  in  Fig.  90,  and  remove  the  bone  between  the  lines  of  section.  The 
amount  of  bone  removed  should  be  as  great  as  possible,  to  permit  wide  range 
of  motion  subsequently. 

Step  3. — From  the  deep  surface  of  the  masseter  dissect  a  flap  about  i  1/2 
inches  long,  with  its  pedicle  above,  consisting  of  about  half  the  thickness  of 
the  muscle.  Pass  the  free  end  of  this  flap  through  the  breach  in  the  bone 
and  suture  it  to  the  pterygoid  (Fig.  91).  Should  the  flap  from  the  mas- 
seter be  insufficient  for  the  purpose,  a  subsidiary  flap  may  be  taken  from  the 
pterygoid. 

Step  4. — Close  the  wound. 


CHAPTER  X. 
ODONTOMATA. 

Odontomata  are  tumors  arising  from  teeth  germs  or  teeth  still  in  process 
of  growth.  Bland-Sutton  described  seven  varieties  of  this  tumor  besides 
the  simple  dental  cyst  which  develops  at  the  root  of  a  dead  tooth.  The 
odontomata  are  often  called  dentigerous  cysts.  The  chief  importance  of  these 
tumors  is  that  they  are  rarely  recognized  prior  to  operation,  that  they  are 
often  wrongly  diagnosed  as  malignant  neoplasms  and  the  whole  jaw  needlessly 
extirpated.     The  tumors  are  non-malignant  and  are  readily  removable. 

Bland-Sutton  writes:  "In  the  case  of  a  tumor  of  the  jaw,  the  nature  of 
which  is  doubtful,  particularly  in  a  young  adult,  it  is  incumbent  on  the  sur- 
geon to  satisfy  himself  before  proceeding  to  excise  a  portion  of  the  mandible 
or  maxilla  that  the  tumor  is  not  an  odontome,  for  this  kind  of  tumor  only 
requires  enucleation."  The  following  operation  performed  by  the  author 
explains  the  principles  of  procedure.  Incision  through  muco-periosteum 
over  the  prominence  of  the  tumor.  With  chisel,  trephine,  or  bur  cut  through 
the  shell  of  bone  (about  two  lines  in  thickness) .  In  the  posterior  part  of  the 
tumor  a  cavity  was  found  containing  a  perfect  premolar  tooth  with  thick 
mucous  membrane  attached  all  round  its  neck.  Tooth  removed.  The  mucosa 
was  attached  to  a  purplish,  soft,  round,  grape-like  tumor  which  filled  the  an- 
terior part  of  the  tumor  or  bone  cavity.  This  was  easily  shelled  out.  The 
cavity  left  was  the  size  of  a  hen  egg,  was  smooth  and  lined  with  mucous 
membrane.  The  root  of  the  first  molar  projected  into  the  cavity.  Extracted 
this  tooth.  Partly  closed  wound  and  packed  with  gauze.  The  tumor  was  a 
typical  odontome.     After  many  weeks  the  cavity  closed  completely. 

A  more  rapid  closure  would  have  been  obtained  had  the  operation  been 
performed  as  follows: 

1.  Free  incision  of  muco-periosteum  over  the  growth. 

2.  Reflection  of  muco-periosteum  from  over  the  whole  external  of  the 
prominent  surface  of  the  tumor. 

3.  Penetration  of  the  bone  and  removal  of  the  contents  of  the  bone  cavity. 

4.  Removal  of  all  the  external  wall  of  the  cavity  and  destruction  of  the 
mucous  membrane  lining  the   rest   of   the   cavity. 

5.  Application  of  the  reflected  muco-periosteal  flaps  to  the  bottom  of 
the  cavity.     Application  of  dressings  to  keep  the  flaps  in  position. 


96 


CHAPTER  XI. 
EXCISION  OF  THE  CHEEK. 

If  a  tumor  is  located  on  the  buccal  surface  of  the  cheek,  is  not  extensive, 
and  does  not  involve  the  skin,  it  may  be  excised  through  the  mouth  by  an 
elliptical  incision  and  the  wound  closed  by  sutures.  Should  the  amount  of 
mucous  membrane  and  subjacent  tissue  removed  be  great,  then,  when  heal- 
ing has  taken  place,  there  may  result  fibrous  anchylosis  of  the  jaw.  To 
prevent  this  contraction,  one  must  fill  the  defect  by  means  of  a  graft  covered 
with  epithelial  tissue.  Of  course,  when  the  anchylosis  is  the  result  of  an  old 
bum  or  similar  lesion  one  must  excise  the  scar  tissue  before  implanting 
the  graft. 

The  Operation. — The  tumor  or  old  scar  tissue  has  been  excised  through 
the  mouth,  leaving  the  defect  a,  b,  c  (Fig.  92).     On  the  neck  trace  the  flap 


Fig.  93. 


D,  E,  F,  the  distal  portion  of  which  consists  of  hairless  skin  large  enough 
to  more  than  fill  the  defect.  Dissect  free  the  flap  outlined.  Be  sure  that 
the  pedicle  is  wide,  thick,  and  so  placed  that  when  turned  into  position  its 
vessels  will  not  be  injuriously  twisted.  Make  an  incision  (X,  Fig.  92)  through 
the  cheek  into  the  mouth.  Through  this  incision  pass  the  flap  D,  E,  F, 
and  suture  its  edges  to  the  margins  of  the  defect  a,  b,  c.  After  the  lapse 
of  ten  days  divide  the  pedicle  of  the  flap  at  X  and  replace  its  remnant  in  its 
normal  position.  Close  the  wound  in  the  cheek.  Close  the  wound  in  the 
neck  partly  by  sliding  the  edges  towards  each  other  and  partly  by  skingrafts. 
[This  closure  of  the  wound  in  the  neck  may  properly  be  attended  to  at  the 
original   operation.] 

7  97 


98 


EXCISION   OF   THE   CHEEK. 


When  it  is  impossible  to  remove  the  tumor  through  the  mouth,  although 
the  skin  is  not  involved  one  may  make  the  incision  A,  B  (Fig.  93)  through 
the  skin  alone,  reflect  the  skin-flaps  X,  Y  (Fig.  94),  and  thus  expose  the  mu- 
cous membrane  and  tumor  (T,  Fig.  94).  Next  excise  the  tumor  and  fill  the 
resulting  defect  by  the  flap  (C,  E,  D,  Fig.  95)  taken  from  the  neck  (or  fore- 
head).    Replace  the  flaps  X  and  Y  and  secure  with  sutures. 


Fig.  94. 


Fig.  96. 


Fig.  97. — {Monod  and  Vanverts.) 


Bardenheuer  has  devised  some  excellent  and  ingenious  methods  of  re- 
pairing defects  in  the  cheek,  defects  left  after  the  removal  of  disease  or  of 
scar  tissue  which  gave  rise  to  fibrous  anchylosis.  Fig.  96  represents  a  case 
in  which  the  mucous  membrane  was  replaced  by  a  flap  of  skin  taken  from 
the  forehead  and  provided  with  an  enormously  wide  and  reliable  pedicle; 


EXCISION   OF   THE   CHEEK. 


99 


the  skin  was  replaced  by  a  flap  of  skin  taken  from  the  neck.  After  healing 
was  secured  the  pedicles  were  divided,  the  wound  trimmed,  and  all  raw  sur- 
faces on  forehead  or  neck  covered  by  skin-grafts.  Fig.  97  represents  a  case 
in  which  Bardenheuer  brought  a  skin-flap  down  from  the  forehead.  The 
flap  was  nourished  through  a  narrow  flap  which  contained  the  supraorbital 
artery.     The  defect  in  the  skin  was  covered  by  a  flap  taken  from  below. 


Fig.  98.  Fig.  99. 

Figs.  98  and  99. — Keaske's  Operation. — (Esmarch  and  Kowalzig.) 


Fig.  100.  Fig.  ioi.  Fig.  102. 

Figs.  100,  loi,  102. — Israel's  Operation. — {Esmarch  and  Kowalzig.) 

The  above  operations  are  described  as  suggestive  types  for  the  repair 'of 
defects  in  the  cheek.  The  operations  of  Kraske  and  Israel  are  also  good 
types  (Figs.  98,  99,  100,  loi,  102). 

In  cases  where  part  of  the  lower  jaw  has  been  removed  and  where  there 
is  a  corresponding  loss  of  substance  in  the  cheek  Sonnenburg  ("Archiv  fiir 
klin.  Chir.,"  Ixxviii,  820)  makes  an  incision  along  the  corresponding  side 
of  the  tongue  (Fig.  103)  and  so  obtains  a  flap  of  tissue  covered  with  mucosa. 


lOO 


EXCISION   OF  THE  CHEEK. 


This  flap  Sonnenburg  sutures  to  the  freshened  upper  edge  of  the  defect  in 
the  cheek  (Fig.  104).  The  oral  side  of  the  defect  being  filled  as  above,  the 
outer  or  skin  side  may  now  be  covered  by  an  appropriate  flap  taken  from  the 
neck. 


Fig.  103. — -(Sonnenburg.) 


Fig.  104. — (Sonnenburg.) 

Hotchkiss'  Operation. — Planned  for  cases  of  extensive  cancer  of  the 
cheek  with  involvement  of  the  jaw. 

Step  I. — Make  the  incision  i,  2,  3,  8,  4,  (Fig.  105)  through  the  skin,  and 
reflect  the  flaps  outlined  so  as  to  expose  the  lower  border  of  the  inferior  max- 


EXCISION   OF   CHEEK. 


lOI 


Fig.   105. — {Hotchkins  Annals  of  Surg.) 


Fig.  106. — {Hotchkins  Annals  of  Surg.) 


Fig.  107. — {Hotchkins  Annals  of  Surg.)  Fig.   108. — {Hotchkins  Annals  of  Surg.) 


I02  EXCISION    OF    THE    CHEEK. 

ilia,  the  platysma  overlying  the  submaxillary  gland,  and  the  deep  structures 
of   the   neck. 

Step  2. — Free  the  anterior  border  of  the  sterno mastoid  exposing  the 
chain  of  glands  extending  from  the  submaxillary  space  to  below  the  level 
of  the  cricoid  cartilage.  From  below  up  remove  en  masse  the  entire  lymphatic 
chain  along  the  internal  jugular  vein  and  beneath  the  sternomastoid  muscle 
until  the  bellies  of  the  digastric  come  into  view  when  the  contents  of  the  sub- 
maxillary space  (both  salivarj'  and  lympahtic  glands)  must  be  dissected 
free  and  retracted  upwards  in  one  piece  (Fig.  io6).  Doubly  ligate  and  divide 
the  external  jugular  and  facial  veins  and  the  external  carotid  artery. 

Step  3. — Expose  the  outer  surface  of  the  lower  jaw  and  prepare  it  for 
section.  Protect  the  neck  wound  with  gauze.  jMake  an  incision  all  around 
the  disease  on  the  face  and  at  a  safe  distance  from  the  disease  (i,  2,  10, 
9,  Fig.  105).  This  incision  penetrates  the  mouth.  Divide  the  lower  jaw  with 
a  Gigli  saw  well  in  front  of  the  growth.  Retract  the  divided  jaw.  Divide  the 
floor  of  the  mouth  along  the  groove  of  the  tongue  severing  the  mylohyoid 
and  hyoglossus  muscles.  Pull  the  lower  jaw  and  attached  structures  out- 
wards, and  if  the  disease  involves  the  upper  jaw  remove  the  affected  bone. 
Disarticulate  and  remove  the  lower  jaw  along  with  the  diseased  tissues 
(Fig.  107). 

Step  4. — In  Hotchkiss'  cases  "the  mucous  membrane  at  the  side  of  the 
tongue  was  united  to  the  cut  edge  of  the  hard  palate,  the  tongue  thus  being 
elevated  as  a  sort  of  wedge  against  leakage  from  the  mouth.  The  edges  of 
the  cut  mucous  membrane  in  front  and  behind  this  were  united  by  suture  and 
the  cut  edge  of  the  mylohyoid  muscle  was  brought  up  over  this  line  of  union 
of  the  mucous  membrane,  and  the  skin-flap  shown  in  Fig.  108  was  then  sutured 
up  to  fill  in  the  defect  in  the  cheek.  A  portion  of  the  incision  in  the  neck 
was  left  unsutured  and  filled  wdth  loose  gauze  packing  extending  up  to  the 
glenoid  and  temporal  fossae"     ("Annals  Surg.,"  Oct.,  1908). 


CHAPTER  XII. 
LOWER  LIP. 

Epithelioma  is  the  most  common  cause  for  removal  of  the  lower  lip.  The 
classical  method  of  removing  labial  cancers  is  by  a  V-shaped  incision. 
This  method  is  applicable  to  cases  in  which  not  more  than  two-thirds  of  the 
width  of  the  lip  is  involved.     The  resulting  deformity  is  slight. 

The  operation  is  performed  as  follows:  A  general  or  local  anesthetic 
having  been  administered,  an  assistant  controls  the  coronary  arteries  with 
his  fingers  and  thumbs;  the  surgeon  rapidly  cuts  through  the  whole  thickness 
of  the  lip  on  each  side  of  the  tumor.  The  two  cuts  thus  made  meet  at  an 
angle  below  the  tumor,  which  is  now  removed.  Before  the  assistant  relaxes 
his  control  of  the  coronary  vessels  the  surgeon  applies  silk  or  silkworm-gut 
sutures,  either  through  the  whole  thickness  of  the  lip  or  with  the  exception 
of  the  mucous  membrane.  The  sutures  are  tied  and  form  a  sufficient  guard 
against   hemorrhage. 

When  performed  as  above,  the  operation  is  very  speedy;  so  speedy,  in 
fact,  that  the  surgeon  may  inadvertently  make  his  incision  approach  a  little 
too  close  to  the  tumor.  In  such  operations  there  is  usually  nothing  to  be 
gained  and  much  may  be  lost  through  great  speed.  A  slight  modification  in 
operating  leads  to  greater  deliberation  and  hence  greater  thoroughness. 

The  surgeon  seizes  the  tumor  and  lower  lip  between  the  finger  and  thumb 
of  the  left  hand,  and  pulls  them  forwards  and  upwards  in  such  a  way  as  to 
guard  against  blood  entering  the  mouth.  Beginning  on  the  lip  margin,  at 
least  one-fourth  of  an  inch  from  the  growth,  a  curved  incision  is  made  down- 
wards until  the  lower  limits  of  the  tumor  are  passed.  This  incision  is  made 
to  but  not  through  the  mucous  membrane.  Bleeding  vessels  are  caught  up 
with  hemostats.  A  similar  incision  is  made  on  the  opposite  side,  and  only 
after  all  bleeding  is  stopped  is  the  mucous  membrane  divided  and  the  growth 
removed.  The  wound  is  closed  as  in  the  previous  operation.  Many  sur- 
geons prefer  to  stitch  the  mucous  membrane  with  catgut  and  close  the  rest 
of  the  wound  with  silk  or  silkworm-gut.  As  a  matter  of  routine,  the  glands 
through  which  the  lymphatics  of  the  lip  drain  should  be  removed  even  if  not 
enlarged.  He  would  be  a  bold  fool  who  would  say  a  field  had  no  seed  in 
it  because  no  sprouting  verdure  was  visible.  Experience  seems  to  show 
that  it  is  unnecessary  to  remove  the  lymphatics  leading  from  the  tumor  to 
the  lymph  nodes,  although  theoretically  such  ought  to  be  removed.  For 
the  sake  of  obtaining  aseptic  healing  of  the  wound  made  in  removing  the 
lymph  glands  this  part  of  the  operation  may  be  performed  through  a  separate 


I04 


LOWER   LIP. 


incision  which  is  closed  before  the  primary  disease  is  attacked.  "The  cap- 
illary plexuses  of  the  skin  and  mucous  membrane  are  continuous  at  the  free 
border  of  the  lips.  The  ducts  of  the  upper  lip,  of  which  there  are  about 
four  on  each  side,  pass  to  the  submaxillary  nodes.  From  the  lower  lip  the 
trunks  from  near  the  angle  of  the  mouth  pass  to  the  submaxillary  nodes, 
while  those  from  the  centre  of  the  lip  pass  to  the  submental  nodes.  There 
are  from  two  to  four  subcutaneous  ducts  and  from  two  to  three  submucous 
ducts  on  either  side.  The  collecting  trunks  passing  to  the  submaxillary 
nodes  do  not  anastomose,  and  the  same  is  true  of  the  submucous  ducts  of 
the  lower  lip.  The  subcutaneous  ducts,  on  the  other  hand,  passing  to  the 
submental  nodes,  anastomose  freely — an  important  fact  in  cormection  with 
the  extension  of  cancer  of  the  lower  lip."     ("Morris'  Human  Anatomy.") 


Collectors  of  upper  lip  ending  in 
submaxillary  nodes 


Collectors  of  lower  lip  ending  in 
same  nodes 


Vessel  passing  to  node  of  internal 
jugular  chain 


Fig.  109. — The  Lymphatics  of  the  Lips. — {After  Dorendorf.) 


The  submental  nodes  ought  therefore  to  be  removed  on  both  sides.  Re- 
member that  some  lymph  nodes  are  closely  attached  to  the  submaxillary 
salivary  glands  and  hence  these  glands  should  be  excised  on  the  affected 
side.  A  continuation  downwards  of  the  incision  for  the  removal  of  the  tumor, 
the  V  incision  being  converted  into  a  Y,  and  elevation  of  the  skin  on  each 
side  of  the  cut  give  excellent  access  to  the  structures  requiring  removal. 

When  there  is  palpable  glandular  involvement  in  the  neck  the  oper- 
ation becomes  similar  or  practically  identical  with  that  required  in  cancer 
of  the  tongue.  (See  Butlin's,  Crile's,  Maitland's  methods  described  in  chap- 
ter on  the  Tongue.) 

Very  superficial  cancers  of  the  lip  may  be  removed  by  a  curved,  more 
or  less  horizontal  incision,  the  mucous  membrane  and  skin  being  subse- 
quently sewed  together. 

A  large  number  of  methods  for  the  removal  of  cancers  of  the  lower  lip 
and  for  remedying  the  resulting  deformity  will  be  found  sketched  at  the  end 
of  this  article. 

Regnier's  Operation. — Step  i. — The  tumor  and  the  whole  of  the  lower 
lip,  from  one  angle  of  the  mouth  to  the  other,  are  removed  by  a  curved  inci- 


LOWER    LIP. 


105 


sion.  In  making  this  incision  it  is  well  to  have  all  bleeding  arrested  before 
the  mucous  membrane  is  divided  and  the  mouth  is  penetrated. 

Step  2. — The  skin  and  mucous  membrane  at  the  edge  of  the  wound  are 
united  by  sutures  (A,  Fig.  no). 

Step  3. — From  the  lower  edge  of  the  middle  of  the  upper  lip  measure  down- 
wards to  the  lower  edge  of  the  middle  of  the  lower  jaw  {e.  g.,  call  the  distance 
2  1/4  inches).  From  the  middle  of  the  wound  (A,  Fig.  no)  measure  downwards 
and  mark  a  point  the  same  distance  below  A  as  the  mental  process  is  below 
the  edge  of  the  upper  lip  (in  our  example,  2  1/4  inches).  Take  a  point,  B,  in 
the  middle  line,  3/4  inch  lower  than  the  above  (i.  e.,  in  our  example,  3  inches 
below  A).  In  the  submental  region  or  in  the  neck,  as  the  case  may  be,  make 
a  curved  incision  parallel  in  the  wound  in  the  lower  lip,  and  having  the  point 
B  as  its  centre.     This  curved  incision  must  be  from  5  to  6  inches  in  length. 


Fig.  1 10. 


Fig.  jii. 


Step  4. — Through  tbe  incision  at  B  dissect  the  skin-flap,  A,  B,  from  the  sub- 
jacent tissues  in  such  a  way  as  to  enter  the  mouth  at  the  line  of  reflection  of 
the  mucous  membrane  from  lip  or  cheek  to  gum.  In  this  way  a  vizor-shaped 
or  double-pedicled  flap  is  formed  and  can  be  slid  over  the  lower  jaw  to  re-form 
the  lower  lip.  The  lower  edge  of  this  flap  is  sutured  to  the  periosteum  at  the 
lower  edge  of  the  jaw  (Fig.  in). 

Step  5. — A  space,  C,  is  left  in  the  submental  region  through  which  any 
enlarged  glands  may  be  removed.  Ogston  maintains  that,  when  the  sub- 
maxillary gland  is  enlarged  and  even  slightly  adherent  to  the  bone,  the  bone 
is  probably  already  involved  in  the  disease  and  ought  to  be  removed.  If 
this  is  the  case,  then  it  is  quite  feasible  to  remove  the  whole  thickness  of  the 
bone  involved,  along  vdth  the  gland,  through  the  triangular  space  C.  The 
skin  of  the  neck  being  very  lax  and  mobile,  it  is  a  simple  matter  to  cover 
at  least  a  large  part  of  the  space  C  with  skin.  Any  uncovered  portions  may 
be  grafted  according  to  the  Thiersch  method. 

Dressings. — Iodoform  gauze  should  be  loosely  packed  between  the  newly 


io6 


LOWER    LIP. 


formed  lower  lip  and  the  upper  part  of  the  external  surface  of  the  lower  jaw. 
Externally  the  usual  antiseptic  dressings  may  be  applied.  The  mouth  should 
be  frequently  washed  with  a  weak  solution  of  permanganate  of  potash  and 
the  dressings  changed  as  required. 

Regnier's  operation  is  capable  of  being  modified  to  meet  many  conditions, 
and  very  great  deformities  may  often  be  avoided  by  its  means.  To  the  writer 
it  has  given  great  satisfaction. 

DOWD'S  OPERATION. 

Step  I. — Make  the  incisions  A,  B  and  C,  D  below  and  parallel  to  the  lower 
jaw.  Be  careful  to  leave  the  point  X  (Fig.  112)  attached  to  the  jaw.  Expose 
and  remove  the  fatty  and  lymphatic  tissue  of  the  whole  submental  and  sub- 
maxillary  region.     Remove   also   the   submaxillary   salivary   glands.     If   the 


Fig.  112. — Dowd's  Operation. 

lymphatics  above  mentioned  are  visibly  and  palpably  enlarged,  continue  the 
incisions  backwards  and  expose  the  carotid  packet  of  vessels.  Remove  the 
lymphatic  glands  in  this  region  whether  they  are  palpably  enlarged  or  not. 

Step  2. — Remove  the  disease  by  means  of  the  incisions  A,  E,  F;  C,  G, 
H;  A,  C.     These  incisions  should  be  1/2  to  3/4  inch  distant  from  the  disease. 

Step  3. — Make  the  incisions  I,  E  and  G,  K  (each  two  inches  or  more  in 
length),  down  to  but  not  through  the  buccal  mucosa.  Divide  the  mucosa 
along  lines  at  least  1/3  inch  higher,  so  as  to  form  a  flap  which  may  be 
stitched  to  the  skin  and  serve  as  mucous  membrane  for  the  new  lower  lip. 

Step  4. — Unite  the  raw  surface  A,  E  to  C,  G  with  sutures.  The  wedge- 
shaped  incisions  L  and  M  may  aid  in  the  approximation  of  the  new  lower  lip. 

Step  5. — Close  the  wounds  A,  B  and  C,  D,  after  providing  for  drainage. 

Trendelenburg's  position  ought  to  be  used  throughout  the  operation. 
In  operating  on  cancer  of  the  lip  it  is  a  good  rule,  where  possible,  to  begin  by 
dissecting  out  the  lymphatics  which  may  be  diseased.  It  is,  of  course,  im- 
perative to  remove  all  evidently  involved  lymphatics,  but  it  is  prudent  to  go 


LOWER   LIP.  107 

futher  and  remove  the  apparently  unaffected  ones  next  in  order.  For  example: 
the  submental  and  submaxillary  group  of  lymphatics  appear  healthy,  or  but 
very  slightly  diseased:  remove  them  and  then  excise  the  primary  disease  of 
the  lip  as  well  as  perhaps  the  fatty  connections  between  the  primary  and  the 
secondary  foci  of  disease;  again,  the  submental  and  submaxillary  group  are 
evidently  diseased:  expose  the  carotid  group  of  lymphatics,  excise  them,  as 
well  as  the  submaxillary,  etc.  One  great  reason  for  beginning  with  the  lym- 
phatics is  that  by  so  doing  the  mouth  is  not  penetrated  until  the  difficulties 
of  the  operation  are  practically  ended. 


Fig.  113. — {Sutton.) 

W.  S.  Sutton  devised  an  ingenious  and  successful  method  of  removing 
tumors  involving  both  upper  and  lower  lips  at  the  angle  of  the  mouth  ("  Journ. 
A.  M.  A.,"  Aug.  20,  1910.  Fig.  113  is  self-explanatory.  Grant's  operation  is 
sufficiently  explained  by  Figs.  114  and  115. 

Nelaton  and  Ombredanne  recommend  the  two  following  operations  as  the 
methods  of  choice  in  cancers  of  different  extent. 

Method  A . 

Step  I. — Excise  the  cancer  by  a  V-shaped  incision.  From  the  apex  of  the 
V  make  one  or  if  necessary  two  incisions  parallel  to  and  a  finger-breadth 
below  the  border  of  the  lower  jaw,  outwards  to  the  line  of  the  carotid  artery 
(Fig.  116).     Excise  the  lymphatics  extensively. 


io8 


LOWER   LIP. 


Step  2. — Close  the  wound  by  suture,  after  providing  for  drainage  (Fig. 
117).  Closure  of  the  wound  produces  a  very  ugly  deformity  of  the  upper  lip. 
To  correct  this  make  an  angled  incision  E,  B,  C  (Fig.  117)  on  each  side  of  the 
mouth.  Suture  the  cut  surface  E,  B  to  the  cut  surface  B,  C.  This  restores 
the  upper  lip.  Along  the  line  E,  D,  C  unite  the  buccal  mucosa  to  the  skin. 
This  gives  a  presentable  lower  lip  (Fig.  118). 


Fig.  114. — Grant  (Bryant's  Op. 
Surg.) 


Fig.  115. — Gra.nt  (Bryant's  Op, 
Surg.) 


Method  B. — For  very  extensive  lesions. 

Step  I. — Excise  the  tumor,  preferably  by  incisions  which  form  a  triangle 
with  its  apex  below,  so  that  a  cut  may  run  down  from  the  apex  to  expose  the 
lymphatics  beneath  the  jaw. 


^!jJl    J_   ,      ^^^g. 


Fig.  116. — (Nelaton  and  Ombredanne.) 

Step  2. — On  each  side  proceed  as  follows:  From  the  angle  of  the  mouth 
make  an  incision  (A,  B,  Fig.  119)  directed  towards  the  inferior  border  of  the 
tragus.  Divide  the  skin  only.  Open  the  mouth.  Mucous  membrane  exists 
under  the  anterior  portion  of  the  cut  A,  B.  Divide  the  mucous  membrane 
parallel  to  but  about  1/3  inch  above  the  skin  incision.  (By  suturing  the  mucosa 
to  the  skin  a  red  border  is  provided  for  the  new  lower  lip.)     Make  the  skin 


LOWER   LIP. 


109 


incision  B,  C  parallel  to  the  wound  made  in  the  excision  of  the  disease.  The 
lower  end  of  the  cut  B,  C,  is  about  a  finger's  breadth  below  the  lower  border 
of  the  lower  jaw.  In  making  the  cuts  A,  B  and  B,  C  do  not  injure  the  parotid. 
Reflect  the  flap  outlined  by  the  cuts  AB,  BC;  to  do  this  it  is  necessary  to  divide 
the  mucosa  vertically  along  the  anterior  edge  of  the  masseter.     Be  careful 


Fig.  117. — {Nclaton  and  Omhredanne.) 


,^^^  j_  V    ^:^^ 


Fig.  118. — {Nelaton  and  Ombredanne.) 

not  to  divide  the  facial  artery  where  it  crosses  the  border  of  the  lower  jaw,  but 
separate  it,  with  the  flap,  from  the  jaw. 

Step  3. — Clear  away  the  lymphatics  and  the  submaxillary  glands  but 
carefully  preserve  the  facial  artery;  if  necessary,  the  facial  vein  may  be  sacrificed. 

Step  4. — Suture  the  mucosa  to  the  skin  on  the  upper  edge  of  the  flap  (see 
Step  2)  so  as  to  form  a  red  border  for  the  new  lower  lip  (X,  A,  Figs.  120  and  121). 


no 


LOWER    LIP. 


Fig.   119. — {Nelaton  and  Ombredanne.)  FiG.  120. — {Nelaton  and  Ombredanne.) 


Fig.  121. — {Nelaton  and  Ombredanne.)  Fig.  122. — {Nelaton  and  Ombredanne.) 


LOWER    LIP. 


Ill 


Step  5. — Suture  the  lower  edge  of  the  mucous  membrane  of  the  new  lip 
to  the  cut  edge  of  the  mucous  membrane  on  the  lower  jaw  (L,  L,  Figs.  96 
and  97).  This  forms  the  line  of  reflection  of  the  mucous  membrane  between 
the  lip  and  the  jaw.  The  rest  of  the  operation  is  sufficiently  explained  by 
Fig.  121  and  122. 

Clark  Stewart's  operation  ("Journ.  A.  M.  A.,"  Jan.  15,  1910)  gives  good 
exposure  of  the  submaxillary  lymph  nodes  and  permits  of  the  excision  of  the 
lymph  nodes,  submaxillary  glands  and  the  tumor  in  one  piece. 

"The  iirst  incision  extends  just  below  the  jaw  from  one  angle  to  the  other 
and  cuts  the  skin  and  platysma  muscle,  which  are  then  carefully  dissected 
down  to  the  level  of  the  thyroid  cartilage  (Fig.  123).     All  tissues  down  to  the 


Fig.  123. — {Stewart,  Jour.  A.  M.  A.) 

muscles  are  then  sectioned  at  this  line  and  a  clean  dissection  is  made  elevating 
all  loose  connective  tissue,  lymph  nodes,  etc.,  in  a  flap  which  extends  laterally 
to  the  great  vessels  on  each  side.  The  facial  artery  and  vein  are  ligated  and 
the  submaxillary  glands  are  loosened  and  raised  in  the  flap  on  each  side. 
Incisions  are  now  made  at  each  side  of  the  epithelioma  far  enough  away  to 
include  all  infiltrated  tissue,  and  these  are  carried  down  to  the  cross-section 
already  made. 

The  lateral  flaps  are  now  dissected  free  from  the  jaw,  keeping  close  to 
the  skin  at  the  lower  part  to  avoid  lymphatics,  and  finally  the  intervening 
central  mass  is  loosened  from  the  jaw  and  removed.  This  contains  the  tumor 
and  a  fan-shaped  mass  of  skin  and  the  deeper  tissues  attached  to  the  lymph 
nodes  of  the  neck,  and  the  submaxillary  gland  by  a  loose  flap  of  tissue  which 
contains  the  connecting  lymphatics. 

The  submaxillary  glands  should  always  be  removed,  not  because  they  are 
infected  in  early  cases,  but  because  there  is  regularly  a  lymph  node  attached 


112  LOWER    LIP. 


to  each  which  is  one  of  the  first  to  be  involved.  In  cases  in  which  not  over 
three-fourths  of  an  inch  of  the  vermilion  edge  of  the  lip  has  been  removed, 
simple  suture  of  the  wound  with  drainage  of  the  submaxillary  fossae  com- 
pletes the  operation.     In  cases  in  which  the  mouth  must  be  extended  on  account 


Fig.   124. — {Stewart,  Jour.  A.  M.  A.) 

of  more  extensive  removal  of  the  lower  lip,  the  procedure  shown  in  the  drawings 
is  convenient. 

The  mouth  is  broadened  by  a  straight  incision  outwards  at  either  or  both 
angles,  and  this  incision  is  carried  down  to  but  not  through  the  mucous  mem- 


FiG.   125. — {Stewart,  Jour.  A.  M.  A.) 

brane;  the  latter  is  then  cut  one-half  inch  higher  and  stitched  to  the  raw 
surface  of  the  new  lip  (Fig.  124).  To  avoid  puckering  of  the  upper  lip  a  tri- 
angle of  the  skin  is  taken  out  of  the  cheek  to  allow  of  the  smooth  drawing 


LOWER   LIP. 


"3 


together  of  the  lower  lip  (Fig.  125).     The  new  chin  should  be  sutured  to  the 
soft  tissues  over  the  lower  jaw  to  exclude  mouth  fluids  from  the  neck  wound." 

CHIN  AND  JAW. 

Occasionally  an  operable  cancer  involves  the  soft  parts  of  the  chin,  the  floor 
of  the  mouth,  and  a  portion  of  the  lower  jaw.  The  following  method  has  proved 
useful  in  such  cases: 

Step  I. — A  stout  thread  is  passed  through  the  tongue  so  as  to  have  command 
over  that  organ. 

Step  2. — An  incision  is  made  through  the  skin  around  the  tumor.  From 
the  lowest  part  of  this  a  cut  is  made  dowTiwards  through  the  skin  of  the  sub- 


FlG.  128. 

mental  region  and  neck  to  a  point  A  (Fig.  126).  The  cut  A,  B,  is  made  through 
the  skin.  The  incision  around  the  tumor  is  deepened  until  the  bone  is  reached, 
but  the  mouth  shovdd  not  be  penetrated  until  all  bleeding  vessels  have  been 
caught.  By  proceeding  thus,  time  is  not  wasted  by  the  necessity  of  swabbing 
blood  from  the  pharynx. 

Step  3. — The  flaps  A,  C  and  B,  D  (Fig.  127)  are  reflected,  giving  easy  access 
to  the  bone.     The  horizontal  ramus  of  the  lower  jaw  is  divided  by  a  chain 
or  finger  saw  on  each  side  of  the  tumor. 
8 


114 


LOWER    LIP. 


Fig.  129.  Fig.  130. 

Figs.  129  .^nd  130. — Bruns. — {Esmarch  and  Kowalzig.) 


Fig.  131.  Fig.  132. 

Figs.   131  and  132. — Estlander. — (Esmarch  and  Kowalzig.) 


Fig.  133.  Fig.   134. 

Figs.  133  and  134. — -Dieffenbach. — (Esmarch  and  Kowalzig.) 


Fig.  135.  Fig.  136. 

Figs.  135  and    136.— (o)    Jaesche;    (b)   Trendelenburg.— (£5worc/i  and  Kowalzig.) 


LOWER   LIP. 


"5 


Step  4. — Posteriorly  to  the  tumor  and  from  below  upwards  the  floor  of  the 
mouth  is  divided  in  such  a  manner  that  all  bleeding  is  invited  and  arrested 
before  the  scissors  or  knife  enters  the  mouth. 

Step  5. — It  is  now  easy  to  remove  all  the  diseased  structures — chin,  jaw, 
floor  of  mouth,  glands,  etc.,  en  masse. 

Step  6.— If  possible,  the  edges  of  the  oral  mucous  membrane  should  be 


Fig.   137.  Fig.   138. 

Figs.   137  and  138. — Burow. — (Esmarch  and  Kowalzig.) 


Fig.  139.  Fig.  140. 

Figs.   139  .axd  iJtO.~Bi.ASivs.~{Esmarch  and  Kowalzig.) 


Fig.  141.  Fig.  142. 

Figs.  141  and  142. — L.axgenbeck. — {Esmarch  and  Kowalzig.) 

united  by  silk  or  catgut  sutures.  The  skin-wound  is  closed  by  silkworm-gut. 
Dressings. — The  floor  of  the  mouth  should  be  lightly  packed  with  iodoform 
gauze.  The  external  wound  should  be  covered  by  an  antiseptic  dressing. 
Frequent  washing  of  the  mouth  mth  a  weak  permanganate  of  potash  solution 
is  necessary.  Food  ought  to  be  given  through  the  stomach-tube,  though  the 
patient  may  drink  water  if  he  so  desires.     It  is  important  in  all  such  cases  to 


ii6 


LOWER   LIP. 


encourage  the  patient  to  leave  his  bed  as  early  as  possible.     This  helps  to 
avoid  the  great  danger  in  such  cases,  viz.,  septic  pneumonia. 

Should  the  first  part  of  Step  6  of  the  previous  operation  be  impossible 
owing  to  lack  of  mucous  membrane,  then  an  attempt  may  be  made  to  supply 
the  defect  as  follows:  In  the  neck  (where  hairs  are  absent)  trace  out  a  flap  of 
skin  (F,  Fig.  128)  in  such  a  position  and  of  such  a  size  that,  allowing  for  shrink- 
age, it  can  be  made  to  fit  into  the  floor  of  the  mouth.  Turn  the  flap  F  up  and 
stitch  its  distal  or  free  end  to  the  anterior  portion  of  the  mucous  membrane 
wound.     The  most  posterior  stitches  unite  the  mucous  membrane  of  the  side 


Fig.  143. 
Figs.  143  and  144. 


-Trelat.- 


Fig.  144. 
-{Monod  and  Vanverts.) 


Fig.  145. 
Figs.  145  and  146. — Serre.- 


Fig.  146. 
-{Monod  and  Vanverts.) 


of  the  mouth  near  the  root  of  the  tongue  to  the  raw  edges  of  the  flap  near  its 
pedicle.     This  gives  an  epithelial  lining  to  the  floor  of  the  mouth.     The  flaps 

A,  C  and  B,  D  (Fig.  128)  are  now  sutured  over  flap  F;  both  flaps,  A,  C  and 

B,  D,  having  been  split  (G)  to  permit  the  passage  of  flap  F  into  the  mouth. 
The  wound  left  by  the  transplantation  of  flap  F  is  to  be  closed  by  sutures  or 
by  Thiersch's  skin-grafts.  Of  course,  a  secondary  operation  will  be  necessary 
to  close  the  hole  G  and  to  divide  the  pedicle  of  flap  F. 

Several  well-known  methods  of  excising  the  lower  lip  and  repairing  the 
defect  are  illustrated  by  Figs.  129  to  146. 


CHAPTER  XIII. 
HARE-LIP. 

Time  to  Operate. — On  the  whole,  it  may  be  taken  that  it  is  better  to 
operate  after  the  patient  has  passed  the  first  two  months  of  life  than  at  an 
earlier  period,  although  many  surgeons  operate  by  choice  within  a  week  or  two 
of  birth. 

Position  of  Patient  and  Surgeon. — Chloroform  having  been  adminis- 
tered, the  patient  should  be  put  in  Rose's  position.  The  shoulders  being 
supported  on  a  pillow,  the  head  is  allowed  to  hang  backwards  over  the  end 
of  the  table.  In  this  posture  the  anterior  nares  are  at  a  lower  level  than  the 
entrance  to  the  trachea,  and  thus  it  is  easier  for  blood  which  has  gathered  in 
the  nose  or  pharynx  to  escape  through  the  nares  than  to  be  aspirated  into  the 
lungs.  For  the  same  reason  much  trouble  caused  by  the  collecting  of  blood 
in  the  pharynx  is  obviated.  Trendelenburg's  position  has  the  same  advan- 
tages. The  surgeon  sits  with  his  back  to  the  window,  opposite  the  patient's 
head.     The  first  assistant  stands  beside  the  patient's  left  shoulder. 

Fundamental  Principles  of  Hare-lip  Operations. — i.  Tension  must 
be  relieved,  so  that  the  fimction  of  the  sutures  is  practically  merely  to  hint 
to  the  edges  of  the  cleft  that  they  must  stay  in  apposition. 

2.  The  edges  of  the  cleft  must  be  freshened  so  that  union  can  take  place. 

3.  This  freshening  must  be  done  in  such  a  way  that  the  edge  of  the  upper 
lip  opposite  the  line  of  suture  is  made  to  project  below  the  normal  level  of  the 
lip.  The  object  of  this  is  to  avoid  the  occurrence  of  a  notch  on  the  lip  after 
the  wound  has  shrunk  when  healing  is  complete. 

4.  The  freshened  edges  of  the  cleft  must  be  brought  together  and  kept 
together. 

SINGLE  HARE-LIP. 

Incomplete  Hare-lip. — The  cleft  in  the  Up  does  not  extend  into  the  nostril; 
it  is  often  a  mere  notch.  It  may  be  unnecessary  to  relieve  tension,  though  when 
the  cleft  is  at  all  extensive  or  wide  this  is  necessary  and  must  be  done  thoroughly. 
Malgaigne's  operation  gives  good  results,  but  Nelaton's  is  the  one  usually  recom- 
mended. These  operations  and  a  few  others  will  be  easily  understood  by  a 
glance  at  Figs.  147  to  152. 

In  incomplete  hare-lip,  when  the  ala  of  the  nose  is  pulled  to  the  side  and  the 
nostril  much  widened,  C.  H.  Mayo  relieves  tension  very  thoroughly,  separating 
the  ala  of  the  nose  from  its  deep  connections;  then  he  makes  his  denudation  at 
the  floor  of  the  nostril  (Fig.  153,  A.  B),  and  by  pulling  the  lip  downwards  and 
introducting  sutures,  converts  the  horizontal  wound  A,  B  into  a  vertical  one 

117 


ii8 


HARE-LIP. 


Fig.  147.  Fig.  148. 

Figs.   147  and  148. — Malgaigne. — {Esmarch  and  Kowalzig.) 


Fig.   149.  Fig.  150. 

Figs.   149  and  150. — Nelaton.- — (Esmarch  and  Kowalzig.) 


Fig.  151.  Fig.  152. 

Figs.   151  and  152. — Mirault. — (Esmarch  and  Kowalzig.) 


Fig.  153. 


Fig.  154. 


HARE-LIP.  119 

(Fig.  154).  The  result  is  obliteration  of  the  notch  in  the  lip  and  correction  of 
the  deformed  position  of  the  ala  of  the  nose. 

Complete  Single  Hare-lip. — Relief  of  Tension. — This  is  one  of  the  most 
important  steps  of  all  hare-lip  operations.  Failure  to  relieve  tension  completely 
is  the  most  common  cause  of  bad  results. 

The  upper  lip  is  everted  and  pulled  upwards  and  outwards  by  the  finger 
and  thumb  of  the  left  hand  (Fig.  155).  The  mucous  membrane  is  incised  at  its 
reflection  from  gum  to  lip,  and  divided  from  the  premolar  region  on  one  side  to 
the  premolar  region  on  the  other  side,  if  necessary.  Through  this  incision, 
with  knife  or  scissors,  one  separates  the  soft  parts  from  the  bones  (keeping 
the  instrument  close  to  the  bone).  Particular  attention  must  be  paid  to  the 
separation  of  the  ala  of  the  nose  from  the  bone  (Fig.  156). 


Fig.  155.  Fig.  156. 

The  dotted  area  represents  the  extent  of  dis- 
section that  is  commonly  required  for  the  relief 
of  tension. 

To  what  extent  must  the  soft  parts  be  separated  from  the  bone  ?  The  answer 
to  the  foregoing  question  is — until  the  edges  of  the  cleft  in  the  lip,  when  placed 
together,  show  a  tendency  to  lie  in  apposition,  so  that  the  sutures  when  intro- 
duced may  be  tied  without  giving  rise  to  tension. 

Freshening  of  the  Edges  of  the  Cleft. — The  methods  of  freshening  the  edges 
of  the  cleft  are  legion.  Only  one  of  the  methods,  viz.,  Collis',  will  be  de- 
scribed here. 

The  Collis  Operation  for  Single  Hare-lip.— Tension  having  been  relieved, 
make  the  incision  A,  B  (Fig.  157)  along  the  line  of  junction  between  mucous 
membrane  and  skin.  Dissect  the  mucous  membrane,  corresponding  to  that 
incision,  from  the  subjacent  tissues  until  the  whole  edge  A,  B  of  the  cleft  is  raw. 
The  mucous  membrane  may  be  entirely  removed  or  may  be  left  as  a  flap  (F, 
Fig.  158)  having  its  pedicle  posteriorly.  If  the  flap  is  left  attached,  it  forms, 
when  the  operation  is  completed,  a  sort  of  valve  covering  the  posterior  surface 
of  the  wound.     In  a  few  weeks  no  trace  of  it  will  be  found. 

On  the  external  edge  of  the  cleft  make  the  incision  C,  E,  D  (Fig.  157) 


I20 


HARE-LIP. 


through  the  whole  thickness  of  the  lip.  At  the  point  E  divide  the  flap  thus 
formed  by  a  horizontal  incision.  This  results  in  the  formation  of  two  flaps, 
C  e'  and  D  e  (Figs.  157  and  158).  Stitch  the  raw  surface  of  the  flap  C  e'  to  the 
highest  possible  part  of  the  raw  surface  A,  B.  This  brings  the  ala  of  the  nose 
into  good  position  and  provides  an  epithelial  covered  floor  to  the  anterior 
nares.     Turn  the  flap  D  e  (Fig.  159)  downwards  and  stitch  it  to  the  lowest 


Etind  e.e^. 


Fig.  157. 


Fig.  158. 


possible  part  of  the  raw  surface  A,  B.  Stitch  the  point  E  (Fig.  159)  to  the 
middle  of  the  raw  surface  A,  B.  When  all  the  sutures  are  in  place  and  tied,  the 
wound  line  will  appear  as  represented  in  Fig.  159. 

This  operation  wastes  no  valuable  tissue  and  gives  a  particularly  long  upper 
lip.  Figs.  160  to  168  sufl&ce  to  illustrate  some  other  well-known  methods  of 
operating. 

Sutures. — One  or  two  deep  sutures  involving  almost  the  whole  thickness  of 
the  lip  must  be  inserted.  The  best  material  for  these  is  silkworm-gut.  Hare-lip 
pins  have  been  discarded,  as  they  cause  too  much  scarring.     Usually  the  deep 

sutures  are  inserted  through  the  skin  and  give 
rise  to  considerable  scarring  at  their  points  of 
entrance  and  emergence;  a  better  plan  is  to 
introduce  the  deep  sutures  from  the  mucous 
surface  and  not  to  involve  the  skin  in  their  bite; 
when  this  is  done,  these  stitches  must  not  be 
removed  until  healing  is  complete,  when  they  will 
generally  be  found  to  have  cut  their  own  way 
out.  If  the  surgeon  endeavors  to  remove  such 
sutures  at  the  end  of  a  week,  he  requires  to  evert 
the  lip,  and  thus  jeopardizes  the  line  of  union.  Several  superficial  cutaneous 
sutures  must  be  introduced;  the  best  material  for  these  is  horse-hair.  Horse- 
hair sutures,  because  of  their  elasticity,  leave  less  scar  than  any  others.  All 
cutaneous  sutures  (superficial  and  deep)  may  be  removed  by  the  seventh  day. 

DOUBLE  UNCOMPLICATED  HARE-LIP. 

When  the  deformity  is  not  complicated  by  the  central  portion  of  the  lip 
being  carried  forwards  towards  the  tip  of  the  nose  by  the  intermaxillary  bone, 
the  following  operation  will  generally  be  found  satisfactory. 


Fig. 


159- 


HARE-LIP. 


121 


Fig.  i6o.  Fig.  i6i.  Fig.  162. 

Figs.  160,  161  and  162. — GiR-^ldes. —  {Esmarch  and  Kowalzig.) 


Fig.  163.  Fig.  164.  Fig.  165. 

Figs.  163,  164  axd  165. — Konig. — {Esmarch  and  Kowakig.) 


Fig.  166.  Fig.  167.  Fig.  168. 

Figs.  166,  167  and  i68.~(Esniarch  and  Kowalzig.) 


Fig.  169. 


Fig.  170. 


^^ r-H 


Fig.  171. 


Fig.  172. 


122 


HARE-LIP. 


Make  the  incisions  A,  B,  C  and  D,  E,  F  (Fig.  169)  through  the  whole  thick- 
ness of  the  lip.  At  the  points  B  and  E  divide  each  of  the  flaps  thus  formed  into 
two.  The  edges  of  the  central  portion  of  the  lip  (Figs.  169,  170,  17.C  G)  are 
now  to  be  pared.  On  each  side  there  are  now  two  flaps,  an  upper  and  a  lower. 
The  raw  surfaces  of  the  upper  flaps  are  to  be  sutured  to  the  lateral  raw  surfaces 
of  G  as  high  up  as  possible.     Corresponding  to  the  lower  edge  of  G,  the  hori- 


FiG.  173.  Fig.   174.  Fk; 

Figs.   173,   174  and  175. — Maas. — {Esmarch  and  Kowahig.) 


Fig.  176.  Fig.  177.  Fig.  178. 

Figs.   176,  177,  and  178. — Hagedorn. — {Esmarch  and  Kowalzig.) 


Fig.  179.  Fig.  180.  Fig.  181. 

Figs.  179,  180  and  181. — {Esmarch  and}Kowalzig.) 


zontal  incisions  H  and  I  (Figs.  170  and  171)  must  be  made  through  the  whole 
thickness  of  the  lip  on  each  side.  This  procedure  permits  the  easy  approxima- 
tion of  the  edges  of  the  cleft  below  the  level  of  the  central  part  (G).  The  two 
lower  flaps  when  their  raw  surfaces  are  sutured  together  form  a  prominence  on 
the  edge  of  the  new  upper  lip.  The  appearance  of  the  wound  when  the  opera- 
tion is  completed  is  represented  in  Fig.  172.  Other  methods  of  operating  are 
sufficiently  illustrated  by  Figs.  173  to  181. 


HARE-LIP. 


123 


DOUBLE  HARE-LIP  COMPLICATED  BY  THE  PRESENCE  OF  THE 

INTERIVLAKILLARY  BONE  HANGING  AT  THE  TIP  OF 

THE  NOSE. 

Some  surgeons  advise  that  the  misplaced  intermaxillary  bone  be  entirely 
removed.  When  this  has  been  done,  it  is  very  difficult  to  secure  union  between 
the  new-formed  upper  lip  and  the  column  of  the  nose.  Undoubtedly  it  is  wise 
to  retain  the  bone  and  replace  it  in  its  proper  position.  An  incision  (Fig.  182) 
is  made  through  the  muco-periosteum  of  the  nasal  septum,  beginning  immedi- 
ately behind  the  intermaxillary  bone  and  extending  backwards  for  3/4  of  an 
inch.  A  fine  periosteal  elevator  or  probe  is  passed  through  this  incision  and 
the  muco-periosteum  raised  on  each  side  of  the  septum  (Figs.  183  and  184) 
from  its  edge  up  to  the  root  of  the  nose.  With  a  strong  pair  of  scissors  a  trian- 
gular piece  of  the  septum  (Fig.  183)  is  now  excised.     This  permits  the  inter- 


FiG.  182. 
(Esmarch  and  Kowahig.) 


Fig.  183. 
(Esmarch  and  Kowahig.) 


Fig.  184. 
{Esmarch  and  Kowalztg.) 


maxillary  bone  to  be  easily  pushed  back  into  position.  It  is  not  absolutely 
necessary  to  trim  off  the  mucous  membrane  covering  the  intermaxillary  bone 
and  those  portions  of  the  superior  maxilla  with  which  it  is  in  contact,  though  it 
is  advisable  to  do  so,  as  union  can  then  take  place  with  rapidity.  If  any  de- 
veloping teeth  are  encountered,  remove  such.  Teeth  which  appear  later  in  bad 
position  are  to  be  treated  by  a  dentist.  Suture  of  the  bone  in  position  is  un- 
necessar}\     The  cleft  in  the  lip  should  be  united  at  the  same  sitting. 

Sometimes  instead  of  excising  a  wedge  from  the  septum  it  is  suflScient  to 
make  a  vertical  cut  through  it  and  slide  that  portion  of  the  septum  anterior  to 
the  cut  back  alongside  the  posterior  portion  (Fig.  184).  Lane  thoroughly  dis- 
approves of  all  these  attempts  to  replace  the  intermaxillary  bone. 


DRESSINGS  AFTER  OPERATIONS  FOR  HARE-LIP. 

Should  tension  on  the  sutures  be  feared,  a  strip  of  adhesive  plaster  may  be 
placed  from  cheek  to  cheek  across  the  upper  lip,  in  such  a  way  as  to  relieve 
tension.     If,  however,  the  soft  parts  of  the  lip  and  cheeks  have  been  sufficiently 


124  HARE-LIP. 

separated  from  the  bones  at  the  beginning  of  the  operation,  then  such  a  measure 
is  unnecessary  and  undesirable,  as  it  simply  irritates  the  already  irritable  patient. 
It  is  not  necessary  to  apply  any  dressing  to  the  wound,  as  nature  soon  seals  it 
with  dried  blood-clot.  Until  the  sutures  are  removed  there  should  be  as  little 
interference  with  the  wound  as  possible.  If  it  is  going  to  heal,  it  will  heal  under 
the  scab,  and  the  best  intentioned  endeavors  to  clean  the  wound  will  merely 
interfere  with  nature's  work  and  do  no  good,  as  cleanliness  can  never  be  attained 
in  such  cases.  Care  must  be  taken  so  to  fix  the  little  patient's  arms  that  scratch- 
ing of  the  wound  is  rendered  impossible. 

When  it  is  desired  to  close  the  cleft  in  the  palate,  which  almost  invariably 
accompanies  extensive  hare-lip,  such  closure  ought  to  be  effected  either  at  the 
same  time  as  the  intermaxillary  bone  is  replaced  or  at  a  former  operation. 


CHAPTER  XIV. 
CLEFT  PALATE. 

The  proper  time  to  operate  for  cleft  palate  is  when  the  patient  is  under 
three  months  of  age;  the  best  method  of  operating  is  inapplicable  in  children 
of  over  six  months.  Brophy  has  operated  on  211  cases  of  cleft  palate  in  babies 
yoimger  than  six  months  without  a  single  death,  yet  the  operation  is  undoubtedly 
not  without  risk.  The  operation  should  be  performed  before  the  closure  of  the 
concomitant  hare-lip.  Brophy  gives  the  following  reasons  for  the  above  practice: 
(i)  The  existence  of  the  hare-lip  gives  more  room  in  which  to  work.  (2)  There 
is  less  nervous  shock  after  an  operation  on  a  child  of  a 
few  weeks  of  age  than  when  the  babe  is  older.  (3)  The 
bones  are  soft.  (4)  After  operation  the  child  will  be 
better  nourished.  (5)  The  muscles  of  the  palate  are 
given  an  opportunity  to  develop  instead  of  atrophy,  and 
the  patient  does  not  get  into  the  habit  of  articulating 
through  the  cavern  of  the  nose. 

Before  operating  see  that  the  patient's  general 
health  is  good  and  that  no  local  conditions  exist  which 
might  interfere  with  repair.  If  adenoids  are  present, 
they  must  be  removed.  For  a  few  days  prior  to  opera- 
tion it  is  well  to  cleanse  the  mouth  and  nasal  cavity  with 
a  saturated  solution  of  boracic  acid  in  glycerin. 

Brophy's  Operation. — Applicable  in  children 
younger  than  three  months;  generally  possible,  though 
not  so  easy,  in  children  up  to,  but  not  beyond,  the 
sixth  month.  The  only  special  instruments  required 
are  two  of  Brophy's  strong  needles  (Fig.  185) ;  a  few 
strands  of  No.  20  silver  wire;  lead  plates  No.  17,  American  gage.  No  special 
mouth-gag  is  necessary,  the  assistant's  fingers  being  suflacient  to  keep  the 
mouth  open  and  the  tongue  depressed.  Immediately  before  operating  the 
writer  swabs  the  parts  with  adrenalin  solution.  This  lessens  hemorrhage. 
During  operation  bleeding  is  easily  controlled  by  pressure  with  pledgets  of 
gauze  wrung  out  of  hot  water. 

The  Operation. — i.  Anaesthetize  the  patient.  Place  in  Rose's  or  the  Tren- 
delenburg position.  Pass  a  stout  thread  through  the  anterior  end  of  the 
tongue  as  a  traction  suture.     This  is  a  great  convenience. 

2.  With  a  knife  pare  thoroughly  the  edges  of  the  cleft  in  the  hard  palate, 
cutting  away  a  little  of  the  bone  itself  to  insure  thoroughness.     Either  pare  or 

125 


Fig.   185. — {Brophy, 
"Dental  Cosmos.") 


126 


CLEFT    PALATE. 


horizontally  split  the  edges  of  the  cleft  in  the  soft  palate.  If  split  thoroughly, 
the  edges  of  the  split  retract  and  so  a  good  raw  surface  is  left  without  any 
loss  of  tissue. 

3.  Thread  a  Brophy  needle  with  strong  silk  or  celluloid  hemp.  Raise  the 
cheek  and  pass  the  threaded  needle  through  the  superior  maxilla  from  without 
inwards  at  a  point  just  back  of  the  malar  process  and  high  enough  to  be  above 
the  palate  (Fig.  186).  When  the  needle  appears  in  the  cleft,  pick  up  the  thread, 
which  it  carries,  with  hook  or  forceps.  Withdraw  the  needle,  leaving  the  loop 
of  thread  in  situ.  Catch  the  ends  of  the  thread  in  a  hemostat.  Through  a 
corresponding  part  of  the  opposite  bone  pass  a  loop  of  thread  in  the  same  manner. 
Pass  this  second  loop  of  thread  through  the  first  and  pull  the  latter  out,  carrying 
with  it  the  former.     We  now  have  a  loop  of  thread  passing  through  both  supe- 


FiG.   186. — (Brophy,  " Dental  Cosmos.") 

rior  maxillary  bones  above  the  palate,  and  when  necessary  through  the  nasal 
septum.  By  means  of  this  thread  pull  a  strand  of  very  strong  silver  wire 
through  the  same  track. 

4.  In  the  same  manner  introduce  one  or  sometimes  two  other  silver  wires 
through  the  anterior  portion  of  the  maxilla  above  the  level  of  the  palate  (Fig. 
186,  A). 

5.  Pass  the  ends  of  the  silver  wire  through  holes  in  lead  plates  moulded  to 
fit  the  convexity  of  the  buccal  surfaces  of  the  bones  (one  plate  on  each  side). 
Draw  the  wires  tight  and  twist  them  together — i.  e.,  twist  the  "right  end  of 
the  anterior  vnre  to  the  right  end  of  the  posterior  vnre  and  the  same  on  the 
leftside."     (B,  Fig.  186). 

6.  With  the  thumbs  forcibly  press  the  two  maxillary  bones  together  until 
the  cleft  is  completely  closed.  Twist  the  wires  once  more  so  as  to  hold  the 
bones  firmly  together. 

7.  Close  the  soft  palate  by  sutures.  The  state  of  the  patient  may  necessi- 
tate this  step  being  delayed  until  another  day.  Do  not  close  the  hare-lip  until 
the  palate  is  completely  closed  and  the  patient  has  recovered. 


CLEFT  PALATE. 


127 


Fig.  187. 


Note  — If  closure  of  the  cleft  by  mere  compression  proves  impossible,  division  of 
the  malar  process  may  be  practised  Make  a  very  small  incision  through  the  mucous 
membrane  over  the  malar  process  of  the  superior  maxilla.  Through  this  divide  the 
process  horizontally,  i,  e.,  parallel  to  the  alveolar  edge,  either  with  a  knife  or  a  small 
chisel,  such  as  dentists  use. 

After-treatment  consists  in  as  great  cleanliness  of  mouth  and  nose  as  can  be 
attained;  in  the  use  of  stimulants,  if  necessary;  and  in  feeding  by  means  of  a 
spoon.  The  plates  and  wire  sutures  remain  in  place  from 
two  to  four  weeks. 

In  unilateral  cleft  palate  the  palatal  process  of  one  side 
has  united  with  the  septum  of  the  nose.  In  such  cases  the 
septum  is  often  very  much  curved,  and  its  lower  portion 
seems  a  continuation  of  the  palatal  process  to  which  it  is 
united.  If,  in  the  course  of  operation,  it  is  diflScult  to 
bring  the  edges  of  the  two  palatal  processes  together,  we  may  cut  a  groove  in 
the  septum  at  the  point  X  (Fig.  160)  and  bring  the  freshened  edge  of  the 
ununited  palatal  process  (P',  Fig.  160)  into  apposition  with  it,  thus  using  a 
part  of  the  septum  to  close  the  defect. 

Uranoplasty  (Arbuthnot  Lane's  Operation). — For  many  reasons  the 
operation  should  be  performed  as  early  as  possible  after  birth.  Before  the 
milk  teeth  erupt  there  is  plenty  of  material  present  to  permit  the  closure  of  al- 
most any  defect  no  matter  how  wide  it  may  be.  The  large  surfaces  of  bare 
bone  left  after  Lane's  operation  heal  very  rapidly. 

Instruments  required. 

I.  Lane's  mouth  gags  with  sharp  teeth  which  bite  into  the  gums.  These 
are  sold  in  pairs  of  proper  sizes.     (Figs.  188  and  189.) 

2.  Lane's  needle  holder  with  very  small 
needles  (Figs.  190  and  191).  This  was 
originally  devised  for  suture  of  the  bile  ducts. 

3.  One  small  strong  knife.  A  Jones' 
tenotome  will  serve  admirably. 

4.  Fine  sharp-pointed  scissors. 

5.  One  strong  hemostat  with  mouse  teeth 
at  the  point. 

6.  Fine  strong  silk  or  hemp. 

7.  A  good  mouse-tooth  dissecting  forceps 
suitable  for  catching  the  tissues  or  the  end 
of  a  needle. 

Type  A. — The  cleft  in  the  hard  palate  is  unilateral.  The  septum  is  con- 
tinuous with  the  hard  palate  on  one  side.  The  alveolus  and  the  soft  palate 
are  also  cleft. 

Step  I. — Formation  of  reflected  flap.  Make  the  incision  7,  5,  6,  through  the 
muco-periosteum  to  the  bone  (Fig.  192).  In  order  to  obtain  plenty  of  tissue 
that  part  of  the  incision  represented  by  the  line  from  5  to  6  is  made  on  the  outer 


Fig.  I 


(Lane.) 


128 


CLEFT   PALATE. 


surface  of  the  alveolus  near  the  reflection  of  the  mucosa  from  the  alveolus  to  the 
cheek.  Make  the  incision  through  the  mucosa  of  the  soft  palate,  but  do  not  m- 
jure  the  musculature.  Reflect  the  outlined  flap  7,  5,  6,  8.  The  pedicle  or 
hinge  of  the  flap  corresponds  to  the  edge  of  the  cleft  in  the  palate. 

In  separating  the  muco-periosteum  from  the  bone  as  the  posterior  palatine 
foramen  is  approached,  an  elevator  pressed  in  between  the  flap  and  the  bony 


Fig.   189. — (Lane.) 

palate  causes  the  posterior  palatine  vessels  and  nerves  to  protrude  for  a  consider- 
able length  in  a  tube  of  periosteum.  This  is  readily  grasped  by  an  efl&cient 
hemostat,  which  is  left  in  place  until  hemostasis  is  assured. 

That  portion  of  the  flap  taken  from  the  soft  palate  consists  of  mucosa  and 
submucosa.  It  is  important  not  to  injure  the  muscles  of  the  palate.  The 
reflected  flap  is  formed  on  the  side  of  the  cleft  which  is  not  attached  to 
the  septum. 

Step  2. — On  the  side  of  the  cleft  attached  to  the  septum  proceed  as  follows: 


CLEFT    PALATE. 


129 


With  forceps  pull  the  uvula  and  soft  palate  forwards  so  as  to  expose  its  nasal 

surface.     Divide  the  mucosa  along  the  posterior  edge  of  the  soft  palate  (4,  3, 

Fig.  192).     Continue  the  incision  across  the  nasal  surface  of  the  soft  palate  to 

the  point  where  the  soft  and  hard  palates  meet  at  the  edge  of  the  cleft  (3,2,  Fig. 

192).     Continue  the  incision  forwards  along  the  edge  of  the 

hard  palate  (2,  i)  and  across  the  alveolus  (i,  9).     The  part 

of  the  incision  affecting  the  hard  palate  and  the  alveolus 

penetrates  the  whole  thickness  of  the  muco-periosteum.     The 

part  of  the  incision  affecting  the  soft  palate  only  penetrates 

the  mucosa  and  submucosa.     Reflect  the  mucous  flap  (2,3,4) 

outlined  on  the  nasal  surface  of  the  soft  palate.     Introduce 

an  elevator  through  the  incision   9,    i,   2    (Fig.    192)    and 

separate  the  muco-periosteum  from  the  hard  palate  and  to  a 

slight  extent  from  the  alveolus  near  the  point  9.     Divide  the 

attachments  of  the  soft  palate  to  the  hard  palate  along  the 

posterior   edge   of   the   latter  lea\dng  intact  the  mucosa  on 

the   oral   side  of  the  palate.      During  Step   2   the  posterior 

palatine  artery  remains  uninjured. 

Step  3. — Turn  the  flap  5,  7,  8,  6,  so  that  its  epithelial 
covered  surface  is  directed  towards  the  nose  and  its  raw 
surface  towards  the  mouth.  Tuck  the  edge  of  flap  5,  7,  8,  6, 
well  under  flap  9,  i,  2,  3,  4,  and  fix  it  in  position  by  two 
rows  of  fine  sutures  (Fig.  193). 

Type  B. — The  cleft  is  wide;  the  septum  is  not  attached 
to  the  palate;  the  alveolus  is  not  cleft. 

Step  I. — Alake  the  flap  i,  2,  3  (Fig.  195)  as  in  Type  A. 
Step  2. — On  the  opposite  side  make  the  incision  6  through 
the  muco-periosteum  along  the  edge  of  the  cleft.  Make  the 
incision  7  and  8  on  the  nasal  surface  of  the  soft  palate  and 
reflect  a  flap  of  mucosa  from  the  soft  palate  as  in  Type  A.  Separate  the  muco- 
periosteum  from  the  hard  palate  and  divide  the  attachments  of  the  soft  to  the 
hard  palate  along  the  posterior  edge  of  the  latter,  leaving  intact 
the  mucous  membrane  on  the  oral  surface. 

Step  3. — Turn  flap  i,  2,  3  over,  with  its  epithelial  surface 
directed  towards  the  nasal  cavity,  so  as  to  cover  the  cleft. 
Tuck  the  free  edge  of  this  flap  well  under  the  flap  10,  6,  7,  8. 
The  triangular  portion  of  this  latter  flap  which  was  obtained 
from  the  nasal  surface  of  the  soft  palate  assists  greatly  in  pro- 
viding a  thick  new  velum  palati. 

Step  4. — Suture  the  edge  of  flap  i,  2,  3,  to  the  base  of  flap  10, 
6,  7,  8  (3,  Fig.  169).  Suture  the  edge  of  flap  of  10,  6,  7,  8  to  the  raw  surface 
of  flap  I,  2,  3  (2,  Fig.  196). 

Note. — If  the  lower  or  free  edge  of  the  nasal  septum  extends  to  the  level  of  the 
cleft  attach  it  to  flap  i,  2  and  3  in  the  following  manner  after  completing  step  2  as 
9 


Fig.  igo.— (Lane.) 


Fig.  191. 
(Lane.) 


I30 


CLEFT  PALATE. 


described:  Make  an  incision  (4.  Fig.  195)  through  the  mucosa  and  periosteum  or 
perichondrium  along  the  middle  line  of  the  septum  with  two  small  transverse 
incisions  (5)  at  either  end^   and  turn  down  laterally  the  narrow  flaps  so  formed, 


Fig.  192. — Uranoplasty. 


Fig.  193. 

leaving  the  cartilage  or  bone  bared  and  exposed  By  placing  flap  i,  2,  3  in 
correct  position,  the  line  along  which  it  will  rest  on  the  septal  margin  can  be 
readily  defined.  Along  the  line  of  contact  with  the  septal  margin  denude  the 
surface  of  flap  i,  2,  3  with  a  sharp    knife.      By   a   series   of   sutures   perforating 


CLEFT  PALATE. 


131 


flap  I,  2,  3  and  the  margin  of  the  septum  if  it  be  not  too  hard,  or  the  flaps  of 
muco-periosteum  if  the  edge  be  bony,  securely  fix  the  flap  to  the  septum  (.i,  Fig- 
196).     Proceed  to  Step  3. 

Type  C. — Double  cleft  palate.     Premaxillary  bone  (P,  M,  Fig.  197)  well  in 
front  of  the  alveolar  arch  and  fixed  to  the  under  surface  of  the  nose;  the  mesial 


Fig.  194. 

segment  (L)  of  lip  is  fixed  to  the  anterior  surface  of  the  premaxilla.  Operation 
by  means  of  reflected  and  pivoting  flaps.  (The  following  description  is  in 
Mr.  Lane's  own  words.) 

"The  reflected  flap  is  obtained  by  an  incision  extending  from  i  along  the 
outer  aspect  of  the  alveolus,  through  2,  and  on  to  3,  when  it  bends  inwards  along 
the  free  margin  of  the  soft  palate  to  the  uvula  4.     The  pivoting  flap  is  obtained 


195. — {Lane. 


by  an  incision  from  5,  along  the  outer  aspect  of  the  alveolus,  through  6,  along 
the  margin  of  the  cleft  in  the  hard  palate  from  7  to  8,  along  the  upper  surface 
of  the  soft  palate  9,  and  then  to  10. 

"The  area  of  mucous  membrane  corresponding  to  the  triangle  8,  9  and  10, 
is  raised  and  reflected  inwards.     The  area  of  muco-periosteum  included  in 


132 


CLEFT    PALATE. 


Fig.   196. — -(Lane.) 


Fig.   197. — (Lane.) 


LANE  S    METHODS. 


13: 


5,  6,  7  and  8  is  raised  from  the  subjacent  bone,  except  at  the  point  of  entry  of 
the  posterior  palatine  vessels  and  nerves,  which  form  the  pivot  on  which  this 
flap  rotates.  The  mucous  membrane  is  stripped  from  the  premaxilla  and  from 
the  free  edge  of  the  septum  in  the  manner  indicated  by  the  dotted  lines,  showing 
incisions  in  the  diagram. 

"Large  flaps  are  cut  from  the  portions  of  lip  forming  the  edges  of  the  cleft, 
and  great  care  is  taken  that  they  have  an  extensive  attachment  at  their  bases. 
The  mucous  membrane  covering  the  lateral  and  lower  aspects  of  the  piece  of 
lip  lying  in  the  front  of  the  premaxilla  is  removed  (L). 


"The  reflected  flap  is  first  put  in  position;  the  mucous  membrane,  where  it 
comes  into  contact  with  the  under  surface  of  the  septum,  having  been  rendered 
raw,  is  secured  to  it  by  sutures.  The  pivoting  flap  is  then  moved  inwards  upon 
the  reflected  flap,  to  which  it  is  united  firmly  by  a  double  row  of  sutures.  Finally 
the  soft  palate  is  closed  in  a  similar  m.anner.     This  is  represented  in  Fig.  198. 

"After  this  the  triangular  areas  of  muco-periosteum  which  were  reflected  from 
the  premaxilla  are  fixed  in  position  (see  Fig.  201),  where  these  are  indicated  by 
Y.  The  flaps  from  the  lips  shown  as  F,  F  are  arranged  with  their  raw  surfaces 
upwards.  These  are  united  to  the  raw  surfaces  of  the  flaps  from  the  premaxilla 
and  of  the  reflected  flap,  and  are  also  sutured  by  their  margins  to  one  another 
and  to  the  free  edge  of  the  pivoting  flap  (see  Fig.  199). 


134 


CLEFT  PALATE. 


Fig.  igg.— (Lane.) 


Fig.  200. — (Lane.) 


Fig.  201. — (Lane.) 


lane's  methods. 


135 


"Lastly,  the  ala  of  the  nose  is  cut  away  from  the  cheek  on  either  side  and  is 
displaced  inwards  where  it  is  united  by  sutures  to  the  septum,  and  is  sewn  to 


Fig.  202. — {Lane.) 


Fig.  203. — {Lane.) 

the  cheek  in  its  new  position.     This  I  have  attempted  to  indicate  in  the  same 
diagram.     Having  brought  the  edges  of  the  lip  into   accurate  position  by 


136 


CLEFT   PALATE. 


means  of  separate  sutures,  two  sutures  of  linen  thread  are  passed  in  the  manner 
indicated  in  Fig.  200.  The  needle  perforates  the  lip  from  behind,  and  is 
made  to  re-enter  the  anterior  aspect  of  the  lip  through  the  same  hole,  and  after 
traversing  the  lip  transversely  it  again  emerges  and  enters  through  the  same  hole. 


Fig.  204. 


Fig.  205. 


the  needle  passing  directly  backwards  through  the  lip.  When  this  thread  is 
made  taut  and  tied  the  opposing  raw  surfaces  of  lip  are  held  in  accurate  position, 
and  no  scar  whatever  results  from  the  presence  of  these  deep  sutures,  which 
can  be  readily  removed  when  they  have  served  their  purpose.  In  Fig.  200 
only  one  cleft  in  the  lip  is  represented." 

Type  D. — Wide  cleft  of  soft  palate.  , 

Step  I. — Reflect  the  flap  i,  5,  6,  7,  8  (Fig.  202) 
with  its  base  at  the  edge  of  the  cleft. 

The  flap  consists  partly  of  muco-periosteum 
from  the  hard  palate  and  alveolus  and  mostly  of 
mucous  membrane  from  the  soft  palate  and  cheek. 
The  flap  must  be  large  enough  to  easily  cover  the 
defect.  Do  not  injure  the  musculature  of  the  soft 
palate. 

Step  2. — From  the  nasal  surface  of  the  soft  palate 
on  the  opposite  side  of  the  cleft  reflect  the  flap  i,  2, 
3,  4  with  its  base  at  the  edge  of  the  cleft. 

Step  3. — Suture  the  two  flaps  together  one  over 
the  other  in  an  overlapping  fashion  (Fig.  203). 

After  the  milk  teeth  have  erupted  some  modifi- 
cation of  Lane's  methods  or  the  following  classical 
operation  may  be  selected. 

The  patient  having  been  anaesthetized,  placed 
in  Rose's  position,  and  a  traction  thread  passed 
through  the  tongue,  a  suitable  gag  is  introduced.  Of  the  numerous  gags 
invented,  probably  Lane's  or  Whitehead's  is  the  best,  but  the  writer  finds  that 
a  piece  of  wood  about  3/4  inch  thick  answers  every  purpose,  and  consequently 
rarely  uses  anything  else. 


Fig.  206.— (Brophy,  "Dental 
Cosmos.") 


CLEFT  PALATE. 


i7 


1.  Denudation. — Seize  the  end  of  the  uvula  on  one  side  with  a  sharp  hook  or 
forceps  (Fig.  204).  With  a  sharp  knife  or  tenotome  remove  a  strip  of  mucous 
membrane  from  the  whole  edge  of  the  cleft.  In  cutting,  do  so  obliquely,  re- 
moving rather  more  membrane  from  the  oral  than  from  the  nasal  side  of  the 
palate.  This  gives  a  more  extensive  raw  surface,  which  is  a  great  advantage. 
When  the  soft  palate  is  very  thick,  its  edge  may  be  split  instead  of  pared. 
Repeat  the  process  on  the  other  side  of  the  cleft. 

2.  With  a  suitable  periosteotome  or  knife  divide  the  muco-periosteum  along 
the  edge  of  the  cleft  in  the  hard  palate.  Separate  all  the  muco-periosteum 
from  the  hard  palate  up  to  the  alveolar  process  (Fig.  205).     For  this  procedure 


Fig.  207. 


Fig.  2og. 


Brophy's  periosteotomes  (Fig.  206)  are  convenient,  but  a  suitable  instrument 
is  easily  extemporized  from  a  dental  spatula  or  even  an  aneurysm  needle. 

3.  The  soft  palate  may  be  said  to  consist  of  three  layers:  (a)  The  nasal 
mucous  membrane;  (6)  the  tissues  attached  to  the  posterior  edge  of  the  hard 
palate;  (c)  the  oral  mucous  membrane. 

Leaving  intact  the  oral  mucous  membrane,  which  is  continuous  from  hard 
to  soft  palate,  divide  with  fine  curved  scissors  both  the  nasal  mucous  membrane 
and  the  tissues  attached  to  the  posterior  edge  of  the  hard  palate.  This  is  one 
of  the  most  important  steps  in  the  operation,  allowing  the  muco-periosteal  flap 
obtained  from  the  hard  palate  to  drop  towards  the  mouth,  and  with  it  the  soft 


Fig.  210. 

palate  (Fig.  207).  Repeat  this  procedure  on  the  opposite  side.  Commonly 
the  raw  edges  of  the  flaps  thus  obtained  will  come  into  apposition  without 
tension.  If  they  do  not,  it  is  necessary  to  make  a  lateral  incision  through  the 
musco-periosteum  parallel  and  close  to  the  alveolus  (Fig.  208)  on  one  or  both 
sides  of  the  mouth,  and  extending  from  the  lateral  incisor  back  to  the  posterior 
margin  of  the  hard  palate.  If  this  is  insufiicient  to  relieve  tension,  Billroth's 
procedure  may  be  adopted  as  follows:  Pass  a  fine  chisel  through  the  posterior 
angle  of  the  lateral  incision;  direct  it  obliquely  inwards  and  upwards  against 
the  hamular  process,  and  with  a  light  blow  from  the  hand  make  it  divide  that 
bone.     The  dislocation  of  the  hamular  process,  increased  if  necessary  by  the 


138 


CLEFT  PALATE. 


use  of  an  elevator,  gives  perfect  relaxation  of  the  velum  palati  and  does  not  injure 
its  musculature.  Incisions  through  the  soft  palate  dividing  Us  muscles  were 
formerly  considered  necessary;  now  they  are  never  admissible. 

C.  H.  Mayo  considers  it  important  to  make  lateral  incisions  (Fig.  208)  on 
both  sides,  not  merely  to  relieve  tension,  but  to  permit  the  use  of  a  relaxation 
tape.  Having  prepared  the  parts  for  the  insertion  of  sutures,  and  having 
made  two  lateral  incisions  close  to  the  alveoli,  he  introduces  a  narrow  tape 
which  surrounds  the  right  and  left  muco-periosteal  flaps  (Fig.  208).  Traction 
on  the  ends  of  the  tape  brings  the  flaps  towards  the  operator,  steadies  them,  and 
facilitates  the  introduction  of  the  ordinary  sutures.  When  the  sutures  are  in 
place  and  tied.  Mayo  crosses  the  free  ends  of  the  tape  and  fixes  them  by  tying 


Fig.  211. — {Brophy,  " Dental  Cosmos.") 


Fig.  212. — {Brophy,  " Dental  Cosmos.") 


a  ligature  around  them  at  this  point  (Fig.  209),  cuts  off  the  superfluous  portions 
of  the  tape,  and  lastly  slides  the  whole  tape  until  that  part  fastened  by  the 
ligature  lies  in  the  nasal  instead  of  in  the  oral  cavity.  The  tape  fastened  as 
above  acts  as  an  efficient  relaxation  suture  or  support;  it  also  drains  secretions 
from  the  nasal  cavity  into  the  mouth.  It  is  remarkable  how  this  very  simple 
contrivance  facilitates  the  operation. 

4.  Suture.  Many  special  needles  have  been  devised  to  overcome  the 
difficulties  met  with  in  closing  palatal  defects.  Of  these,  the  Deschamps 
(Fig.  210)  is  perhaps  the  best,  although  it  is  usually  made  too  large.  The 
writer  finds  that  he  can  discard  such  special  instruments  by  using  very  small, 
full  curved  needles,  grasped  in  a  long-necked  needle-holder,  and  passing  each  end 
of  the  thread,  armed  with  a  needle,  from  the  nasal  to  the  oral  side  of  the  palate, 
i.  e.,  from  within  outwards.     The  usual  method  of  suturing  is  to  begin  at 


CLEFT   PALATE.  I39 

the  uvula  and  work  forwards,  being  careful  to  evert  the  edges  of  the  wound  when 
the  flaps  from  the  hard  palate  are  being  united.  Silk  or  cellaloid  hemp  are 
the  materials  used. 

Brophy  puts  in,  as  a  preliminary,  tension  sutures  of  No.  22  silver  wire, 
fixing  these  on  lead  palates  (Figs.  211  and  212).  He  claims  that  the  use  of 
these  obviates  the  necessity  of  lateral  incisions,  and  that  the  lead  plates  act  as 
a  splint,  securing  rest,  and  hence  better  results.  The  fact  that  numbers  of 
Brophy's  cases  have  passed  the  supreme  test  of  successfully  reading  aloud  be- 
fore professional  societies  makes  his  opinions  and  procedures  worthy  of  the 


Fig.  213. 

Z.  and  Q.  Line  of  separation  of  attachments  of  velum  to  hard  palate.     X,  Y,  Z,  Q.  Area 

in  which  muco-periosteum  (continuous  with  the  velum)  is  separated  from  the  bone. 

gravest  consideration.  C.  H.  Peck  recommends  the  use  of  a  dental  plate  to 
protect  the  united  palate.  The  plate  must  of  course  be  removed  frequently 
for  the  sake  of  cleanliness. 

After-treatment. — Liquid  or  soft  food  is  alone  permissible.  Antiseptic 
sprays  may  be  used  if  not  annoying  to  the  patient.  The  patient  should  get  out 
of  bed  and,  in  suitable  weather,  out  of  doors  as  soon  as  possible.  The  sutures 
must  not  be  removed  earlier  than  the  seventh  day  after  operation. 

Partial  Cleft  Palate. — When  there  is  a  cleft  of  the  soft  palate  alone  and 
the  edges  can  be  brought  together  without  tension,  one  is  content  to  pare  the 
edges  and  apply  sutures.  When  the  cleft  in  the  soft  palate  reaches  close  to  the 
hard  or  when  the  latter  is  partially  cleft,  it  is  absolutely  necessary  to  relieve 
tension.  This  is  done  in  the  same  fashion  as  in  complete  cleft  palate  by  di- 
viding the  attachments  of  the  velum  to  the  hard  palate  and  by  separating  the 
muco-periosteum  from  the  bone  to  as  great  an  extent  as  may  be  necessary 
(Fig.  213). 


CHAPTER  XV. 
TONGUE. 

When  a  small  tumor  exists  near  the  tip  of  the  tongue,  it  may  be  removed 
by  means  of  a  V-shaped  incision. 

Dieffenbach's  Operation. — Local  antesthesia  usually  suffices.  If  a  general 
anaesthetic  is  used,  the  mouth  must  be  kept  open  during  the  operation  by  a 
mouth-gag.  Pull  the  tongue  forwards  by  means  of  a  volsellum  or  a  stout 
thread  passed  through  its  tip.  At  a  point  on  each  side  of  the  tumor,  and  about 
3/4  inch  from  it,  pass  a  long  silk  thread  through  the  whole  thickness  of  the 
tongue  in  such  a  manner  that  the  loop  of  the  thread  is  under  the  tongue,  while 
its  two  free  ends  emerge  from  punctures  on  the  dorsum.  (Fig.  187). 


Fig.  214. 

Excise  the  tumor  and  a  wedge-shaped  portion  of  the  whole  thickness  of  the 
tongue  by  the  converging  incisions  A  B,  A  C  (Fig  214).  The  excision  is  most 
easily  effected  with  the  scissors.  The  bleeding  is  now  liable  to  be  sharp. 
Tighten  and  tie  the  suture  which  has  already  been  introduced.  This  stops  all 
hemorrhage.  Introduce  a  few  more  stitches  so  that  the  wound  is  neatly 
closed  (Fig.  215). 

The  only  after-treatment  required  is  frequent  cleansing  of  the  mouth  with 
non-poisonous  antiseptic  washes. 

Excision  by  Elliptical  Incisions. — Small  tumors  of  the  tongue  may  be  ex- 
cised under  cocain  anaesthesia  by  means  of  elliptical  incisions  surrounding  them. 
As  soon  as  the  neoplasm  is  removed,  bleeding  is  stopped  by  the  application  of 
a  few  sutures  which  at  the  same  time  close  the  wound. 

COMPLETE  REMOVAL  OF  THE  TONGUE. 

As  a  preliminary  to  any  operation  for  extirpation  of  the  tongue  it  is  necessary 
to  clean  the  mouth.     The  mouth,  especially  in  cases  of  cancer,  is  a  filthy  cavern. 

140 


WHITEHEAD  S    OPERATION.  I4I 

The  teeth,  usually  decayed,  are  covered  with  tartar  and  other  abominations. 
The  mouth  should  be  thoroughly  washed  with  antiseptic  solutions,  the  teeth 
vigorously  brushed,  or,  better,  cleansed  by  a  good  dentist,  and  loose  teeth  should 
be  removed.  Very  many  methods  of  operating  have  been  devised,  but  only 
a  few  of  them  will  be  described. 

I.  Whitehead's  Operation. — The  following  description  is  taken  almost 
entirely  from  an  article  by  WTiitehead: 

1.  The  patient  should  be  placed  in  a  sitting  posture;  the  head,  firmly  held, 
should  be  incUned.  forwards  so  that  blood  may  escape  easily.  The  light  must 
be  good  and  have  direct  access  to  the  mouth.  The  patient's  mouth  and  the 
surgeon's  axilla  should  be  at  about  the  same  level. 

2.  During  the  first  stages  of  the  operation  anaesthesia  should  be  complete, 
but  afterwards  only  partial  insensibility  should  be  maintained. 

3.  A  good  gag  is  essential.  It  must  be  one  which  will  not  slip  and  will  not 
embarrass  respiration.  [Whitehead's  gag,  with  the  tongue  depressor  absent, 
is  probably  the  best.]     With  this  the  mouth  is  opened  as  widely  as  possible. 

4.  A  firm  Hgature  should  be  passed  through  the  tip  of  the  tongue  for  the 
purpose  of  traction. 

5.  The  tongue  is  retained  within  the  mouth  principally  by  means  of  the 
frenum  and  the  attachments  to  the  anterior  pillars  of  the  fauces.  These  and 
the  reflection  of  the  mucous  membrane  between  the  tongue  and  jaw  must  be 
divided  with  scissors.  Should  any  spouting  vessels  be  seen,  they  must  at  once 
be  caught  in  forceps  and  twisted;  general  oozing  of  blood  may  be  neglected, 
because  as  soon  as  the  main  arteries  are  discovered  and  twisted  all  bleeding 
ceases.  "There  is,  in  reality,  no  difficulty  in  determining  the  actual  position 
of  the  lingual  arteries,  as  they  are  practically  invariably  found  in  the  same 
situation  and  it  requires  very  little  experience  to  seize  them  with  a  pair  of  for- 
ceps before  dividing  them."  The  rest  of  the  tongue  may  be  cut  away  without 
difficulty.  Before  completely  removing  the  tongue  it  is  wise  to  pass  a  ligature 
through  the  glosso-epiglottidean  fold.  This  ligature  may  be  left  in  place  for 
twenty-four  hours,  and  permits  one  to  pull  forwards  the  epiglottis  should 
respiration  be  interfered  with  at  any  time.  Traction  on  this  ligature  of 
itself  arrests  hemorrhage  and  makes  it  an  easy  matter  to  secure  any  bleeding 
vessel. 

6.  Wash  the  wound  wilh  an  antiseptic  solution. 

7.  Paint  the  wound  with  iodoform  styptic  varnish.  The  varnish  is  made 
by  substituting  for  the  alcohol  ordinarily  used  in  the  preparation  of  Friar's 
balsam  a  saturated  solution  of  iodoform  in  ether  9  volumes,  and  turpentine  i 
volume. 

After-treatment. — Encourage  the  patient  to  sit  up  and  move  about  even 
as  early  as  the  day  following  the  operation.  Give  liquid  food  by  the  mouth 
as  early  and  freely  as  possible.  If  necessary,  supplement  oral  feeding  by  the 
use  of  nutrient  enemata.  The  mouth  is  frequently  washed  and  the  varnish 
is  reapplied  daily. 


142 


TONGUE. 


In  the  hands  of  Whitehead  this  operation  has  had  remarkable  primary 
results.  Up  to  1891  he  had  performed  it  66  times  with  but  three 
deaths. 

When  it  is  necessary  to  remove  only  one-half  of  the  tongue,  the  operation 
is  practically  the  same  as  above,  except  that  the  organ  is  split  in  the  middle  line 
and  the  diseased  half  alone  excised. 

II.  Regnoli-Billroth  Operation. — Step  i. — Pass  a  stout  thread  through 
the  tongue  for  purposes  of  traction. 

Step  2. — Make  an  incision  through  the  skin  and  subcutaneous  tissue  from 
the  anterior  margin  of  one  masseter  muscle  to  the  anterior  margin  of  the  other 
masseter.     This  incision  follows  the  lower  edge  of  the  lower  jaw  (Fig.  216). 

Reflect  the  skin-flap  thus  outlined.  The 
submaxillary  region  now  lies  exposed.  If 
more  room  is  desired,  the  posterior  ends  of 
the  original  incision  may  be  extended  back- 
wards to  the  angles  of  the  lower  jaw. 

Step  3. — With  scissors  or  knife  penetrate 
the  mouth  from  below  upwards  immedi- 
ately behind  the  symphysis.  Be  careful 
not  to  injure  the  periosteum.  Separate  the 
structures  composing  the  floor  of  the  mouth 
from  the  lower  jaw  as  far  back  as  the  anterior 
pillars  of  the  fauces.  Any  bleeding  vessels 
are  caught  up  by  forceps  and  either  twisted 
or  ligated.  The  tongue  with  its  traction 
thread  is  pulled  out  through  the  submental  wound  and  its  posterior  connections 
divided  with  scissors. 

Step  4. — If  there  is  hemorrhage  from  the  stump  and  it  is  not  easy  to  locate 
the  bleeding  point,  hook  the  forefinger  into  the  pharynx  and  pull  forwards. 
This  simple  manoeuvre  brings  the  whole  stump  within  reach  and  the  hemor- 
rhage is  easily  controlled  by  forceps  or  suture.  A  few  sutures  of  silk  worm- 
gut  judiciously  inserted  lessen  the  extent  of  raw  surface. 

Step  5. — Put  an  iodoform  gauze  drain  in  place  and  close  the  remainder  of 
the  wound  with  interrupted  silkworm-gut  sutures. 

During  this  operation  all  affected  or  suspected  lymphatic  tissue  must  be 
removed  from  the  submaxillary  region. 

III.  Sedillot's  Operation. — In  cases  of  lingual  cancer  where  the  floor  of 
the  mouth  and  the  jaws  are  not  affected,  Kocher  ("  Operationslehre,"  fourth 
edition)  strongly  advocates  Sedillot's  operation.  The  only  disadvantage  of 
the  procedure  is  that  excision  of  affected  or  suspected  lymph-glands,  etc., 
if  done  at  the  same  time  as  the  primary  operation,  leaves  too  large  and  irregular 
a  wound,  so  that  infection  can  scarcely  be  avoided.  Kocher  recommends  that 
the  glands  be  excised  at  a  second  operation.  Supposing  that  the  disease  affects 
the  edge  of  the  tongue  posteriorly  and  has  spread  to  its  base,  to  the  anterior 


Fig.  216. — {Esmarch  and  Kowalzig.) 


sedillot's  operation.  143 

pillar  of  the  fauces,  the  soft  palate,  and  the  lateral  wall  of  the  pharynx,  the 
operation  is  carried  out  as  follows: 

Median  division  of  the  lower  lip,  chin,  and  skin  in  submental  region  as  far 
as  the  hyoid  bone  (Fig.  217).  Hemostasis.  Division  of  the  lower  jaw  in  the 
middle  line.  Separation  of  the  divided  halves  of  the  jaw  with  sharp  hooks. 
Median  division  of  the  geniohyoid  and  genioglossal  muscles.  By  means  of  a 
traction  thread  pull  the  tongue  out  and  towards  the  sound  side.  Divide  the 
mucous  membrane  of  the  floor  of  the  mouth  backwards  at  the  margin  of  the 
tongue.  This  exposes  the  lingual  vein,  running  backwards  and  outwards 
over  the  lateral  surface  of  the  hyoglossus;  also  the  lingual  nerve  near  the  border 
of  the  tongue,  immediately  under  the  mucous  membrane.  The  hypoglossal 
nerve  is  exposed  at  the  outer  surface  of  the  hyoglossus,  over  which  it  runs  in- 
wards and  forwards.  Between  the  hyoglossus  and 
genioglossus  lies  the  lingual  artery,  easily  recog- 
nized and  tied.  Divide  the  hyoglossus  with  the 
cautery  (Kocher  divides  all  the  muscles  around 
the  tumor  with  the  cautery).  Put  great  traction 
on  the  tongue  and,  using  the  cautery,  divide  the 
mucous  membrane  posteriorly,  along  a  line  remote 
from  the  disease.  If  the  disease  extends  to  the 
palate  and  pharynx,  divide  the  styloglossus  muscle, 
and  with  it  the  glossopharyngeal  nerve.  After 
dividing    the   mucous   membrane  in   front   of   the  Fig.  217. 

tonsil  it  can  be  lifted  up  by  blunt  dissection,  even 

when  diseased,  until  the  internal  pterygoid  muscle  is  exposed.  Divide,  with 
the  cautery,  the  soft  palate  so  far  as  it  is  diseased,  and  with  it  the  tensor  and 
levator  palati  muscles.  Now  divide  the  mucous  membrane  on  the  posterior 
wall  of  the  pharynx  as  far  as  the  longus  colli  muscle  and  forwards  to  the 
base  of  the  tongue.  All  this  can  be  done  under  full  guidance  of  the  eye. 
Lastly,  with  the  cautery,  divide  the  tongue  itself,  remote  from  the  disease, 
and  sever  its  nerves,  muscles,  and  vessels  (after  applying  ligatures),  or  such 
of  these  as  penetrate  the  neoplasm.  Preserve  as  many  nerves  and  muscles  as 
possible  so  as  to  interfere  with  deglutition  to  the  minimal  extent.  Ability  to 
swallow  is  the  greatest  preventive  against  subsequent  pneumonia.  Rub  the 
wound  with  a  small  amount  of  xeroform.  Wire  the  divided  jaw.  Do  not 
elevate  the  periosteum  when  drilling  the  bone.  Close  the  wound  in  the  soft 
parts,  providing  for  gauze  drainage  immediately  in  front  of  the  hyoid  bone. 
If  the  patient  is  placed  in  the  Trendelenburg  position,  the  operation  can  be 
done  under  a  general  anaesthetic  without  any  preliminary  tracheotomy.  The 
operation  is  suitable  for  all  cases  except  those  in  which  the  jaw  is  affected. 

After -treatment. — Until  the  patient  is  able  to  sit  up,  he  should  be  kept  in 
Trendelenburg's  position.  On  the  day  following  the  operation  he  should  try 
to  sit  up  and  attempt  to  swallow  tea  or  wine  with  water.  Nourishment  must 
be  administered  through  an  esophageal  tube. 


144  TONGUE. 

IV.  Von  Langenbeck's  method  of  excising  the  tongue  is  very  similar 
to  that  of  Sedillot,  and  thus  requires  no  special  description,  except  as  regards 
the  incision.  On  the  side  corresponding  to  the  disease  make  an  incision  from 
the  corner  of  the  mouth  vertically  downwards  to  the  border  of  the  lower  jaw, 
and  continue  it  downwards  to  the  side  of  the  hyoid  bone  (Fig.  217).  The 
upper  portion  of  the  cut  divides  the  lower  lip  and  gum,  penetrating  to  and 
exposing  the  lower  jaw;  the  lower  or  submental  portion  at  first  penetrates  only 
the  skin  and  superficial  fascia.  Through  the  lower  part  of  the  incision  excise 
all  suspected  glands  (lymphatic  and  salivary)  and  Hgate  the  lingual  artery. 
Divide  the  jaw  along  the  line  of  incision  after  boring  holes  for  subsequent 
wiring.     With  strong  hooks  separate  the  segments  of  the  jaw.     The  tongue 

and  floor  of  the  mouth  are  well  exposed  by  this 
procedure  and  can  be  dealt  with  according  to  the 
principles  already  laid  down. 

V.  Kocher's  Method. — In  certain  cases  of 
extensive  carcinoma,  and  always  when  the  disease 
involves  the  lower  jaw,  Kocher  advises  the  following 
operation: 

Step  I. — Put  the  patient  in  Trendelenburg's  posi- 
tion.    Pass  a  stout  thread  through  the  tongue  for 
P  „  purposes  of  traction. 

Step  2. — Beginning  immediately  below  the  sym- 
physis of  the  lower  jaw,  make  an  incision  downwards  to  a  point  a  little 
above  the  hyoid  bone;  from  here  cut  backwards  to  the  anterior  margin  of  the 
sternomastoid.  Once  more  change  the  direction  of  the  incision  and  continue 
it  upwards  along  the  margin  of  the  sternomastoid  to  a  point  near  the  level  of 
the  lobe  of  the  ear  (Fig.  218). 

Step  3. — Reflect  upwards  the  skin-flap  thus  outlined. 

Step  4. — Excise,  en  masse  if  possible,  all  the  enlarged  glands  under  the  upper 
end  of  the  sternomastoid  and  under  the  angle  and  horizontal  ramus  of  the  jaw. 
Carefully  dissect  free  the  anterior  border  of  the  sternomastoid,  exposing  the 
carotid  packet  of  vessels  and  the  great  horn  of  the  hyoid.  Excise  the  glands  in 
this  region. 

Step  5. — If  the  cancer  affects  the  floor  of  the  mouth,  the  fauces,  or  jaw,  it  is 
wise  to  ligate  the  facial  vein  and  the  external  carotid  artery. 

Step  6. — Expose  clearly  the  anterior  belly  of  the  digastric  through  its  whole 
length,  and  ligate  the  veins  under  it.  From  below  upwards  dissect  free  the 
packet  of  glands  exposed  until  the  entire  posterior  belly  of  the  digastric  and 
the  stylohyoid  muscles  lie  free  in  the  posterior  inferior  part  of  the  wound. 
Detach  the  mass  of  glands  (lymphatic  and  salivary)  from  the  lower  jaw. 

Step  7. — At  the  posterior  end  of  the  great  horn  of  the  hyoid  divide  the  in- 
sertion of  the  hyoglossus  muscle.  This  exposes  the  lingual  artery.  Tie  the 
artery,  but  preserve  the  hypoglossal  nerve. 

Step  8. — The  lower  surface  of  the  mylohyoid  muscle  now  lies  exposed  and 


kocher's  operation.  145 

on  it  the  mylohyoid  nerve.  At  the  posterior  margin  of  the  muscle  penetrate 
the  mouth  (guided  by  a  finger  in  the  mouth)  after  once  more  noting  the  extent 
and  limits  of  the  disease.  Beginning  at  this  opening,  divide  the  oral  mucous 
membrane  along  a   line   remote   from   the   disease.     Attend   to   hemostasis. 

Step  9. — Divide  the  lingual  muscles  at  the  hyoid  and  remove  all  infiltrated 
tissue.  It  is  easy  to  pull  the  tongue  out  through  the  wound  as  soon  as  the 
oral  mucous  membrane  has  been  divided. 

If  a  preliminary  tracheotomy  has  been  done,  the  entrances  to  the  larynx 
should  be  packed  with  sterile  gauze  as  soon  as  the  pharynx  is  opened. 

After-treatment. — Leave  the  lower  part  of  the  wound  open  so  that  the  laryn- 
geal pack  may  be  changed  frequently.  Every  time  the  dressings  are  changed 
(and  this  must  be  done  very  frequently)  administer  plenty  of  nutritious  food 
by  means  of  an  esophageal  tube.  As  long  as  the  mechanism  of  deglutition  is 
seriously  disturbed  keep  the  patient  in  more  or  less  of  the  Trendelenburg 
position  except  when  he  stands  or  sits  up.  As  long  as  deglutition  is  poor  the 
patient  must  not  lie  horizontally;  he  must  either  sit  up  or  lie  with  his  head  and 
shoulders  low.  The  object  of  this  care  is,  of  course,  to  avoid  pneumonia  from 
the  entrance  of  secretions  into  the  air  passages. 

The  question  as  to  whether  the  last-mentioned  operation  should  or  should 
not  be  preceded  by  a  tracheotomy  is  much  discussed.  Kocher  and  Jacobson 
are  strong  advocates  of  this  as  a  preliminary. 

The  advantages  of  tracheotomy  are  the  possibility  of  easy  anaesthetization; 
of  plugging  the  pharynx  with  gauze,  thus  avoiding  inspiration  of  blood,  and 
of  greater  freedom  in  operating. 

Butlin  advocates  preliminary  laryngotomy  as  a  safe  and  convenient  sub- 
stitute for  tracheotomy. 

When  removal  of  the  whole  base  of  the  tongue  is  not  necessary  Crile  passes 
closely  fitting  rubber  tubes  through  the  nares  into  the  pharynx,  opposite  the 
epiglottis,  pulls  the  tongue  well  forwards  and  then  closely  packs  the  pharynx 
with  gauze.  The  two  tubes  after  emerging  from  the  anterior  nares  are  con- 
nected by  a  Y,  of  glass  or  metal,  to  a  single  tube  and  through  this  the  anaes- 
thetic is  administered. 

The  opponents  of  preliminary  tracheotomy  believe  that  this  operation, 
while  decreasing  the  danger  of  pneumonia  from  inspiration  of  blood,  yet  makes 
the  patient  subject  to  a  greater  danger  of  contracting  pneumonia  from  other 
causes.  If  tracheotomy  is  decided  on,  it  should  be  performed  several  days 
before  the  tongue  is  attacked,  to  permit  the  patient  to  become  accustomed  to 
the  new  conditions  of  respiration  before  his  powers  are  taxed  by  the  very 
severe  operation  he  is  to  undergo. 

VI.  Butlin's  Method.* — (A)  The  disease  does  not  involve  the  floor  of  the 
mouth. 

Perform  a  preliminary  laryngotomy  (p.  197). 

*Butlin,  "Op.  Surg.  Malignant,  Dis.,"  second  ed..;  "Brit.  Med.  Jour.,"  Feb.  11, 
1905. 

10 


146 


TONGUE. 


Pack  the  pharynx  to  prevent  blood  gravitating  into  the  larynx. 

Step  I. — By  Whitehead's  method  or  some  modification  thereof,  remove  the 
local  disease  with  3/4  inch  of  apparently  healthy  tissues  around  it  in  every 
direction.  Where  the  disease  is  on  the  border  of  the  tongue,  it  is  best  to  remove 
that  half  of  the  tongue  to  an  inch  behind  the  cancer. 

After  about  nine  days,  when  the  patient  it  able  to  take  plenty  of  liquid  food, 
proceed  to  Step  2. 

Step  2. — Make  an  incision  along  the  anterior  border  of  the  sternomastoid 
from  near  the  mastoid  process  to  the  sternoclavicular  articulation.  Make  an 
incision  from  the  symphysis  menti  to  meet  the  previous  incision,  just  above 
the  thyroid  cartilage.  Reflect  the  two  triangular  flaps  of  skin  thus  outlined 
and  expose  the  platysma  myoides  and  fat  of  the  anterior  triangle  of  the  neck. 


Fig.  219. — Butlin's  Method  for  Excision  of  the  Tongue. 
Sketch  indicating  the  position  of  the  most  important  lymph  nodes,  all  of  which  are  suppose 
to  have  been  dissected  out  and  removed,     i.  Location  of  submental  group  lymph  nodes.     2. 
Location  of  submaxillary  group  lymph  nodes.     3.  Location  of  parotid  group  lymph  nodes.     4. 
Location  of  carotid  group  lymph  nodes. 


Step  3. — Beginning  below,  expose  the  sternomastoid  and  retract  it  back- 
wards. Expose  the  carotid  packet  of  vessels,  dissecting  from  below  upwards, 
and  separate  from  it  every  particle  of  fat,  whether  superficial  or  deep,  anterior 
or  posterior.  Be  careful  to  remove  the  fat  between  the  parotid  and  the  vessels. 
All  this  fat  ought  to  be  left  attached  to  that  of  the  rest  of  the  anterior  triangle, 
otherwise  the  operation  is  liable  to  be  incomplete  (Fig.  219).  Working  from 
the  region  of  danger  (carotid  packet)  and  from  below  upwards,  remove  en 
masse  all  the  fat  in  the  anterior  triangle  and  with  it  the  submaxillary  salivary 
gland,  leaving  the  muscles  quite  bare.     In  the  submental  region  complete  the 


BUTLIN  S    OPERATION.  147 

dissection  by  searching  between  the  geniohyoid  muscles,  lest  a  gland  be  over- 
looked. 

If  the  disease  involves  the  contents  of  the  carotid  packet,  these  must  also 
be  removed.  The  internal  jugular  vein  more  often  requires  removal  than  does 
the  carotid  artery. 

Step  4. — Place  one  strip  of  gauze  in  the  submaxillary  triangle  beneath 
the  jaw  and  another  between  the  parotid  and  the  vessels.  Bring  the  ends  of 
the  gauze  out  at  the  lowest  part  of  the  wound.  Provide  tubular  drainage  also. 
Close  the  wound.  Damage  to  the  parotid  will  permit  a  leakage  of  saliva,  but 
this  ceases  in  a  few  days. 

The  principles  of  Butlin's  operation  are:  (i)  Operation  in  two  stages  is 
much  safer  than  in  one.  (2)  The  glands  are  involved  very  early  in  lingual 
cancer,  but  the  lymphatic  vessels  between  the  primary  lesion  and  the  secondary 
seem  to  escape. 

Mr.  Butlin's  results  have  been  so  remarkable  that  no  apology  is  necessary 
for  reproducing  the  statistics  of  seventy  cases  in  which  he  was  permitted  to 
complete  the  operation  in  the  manner  he  advocates.  A  study  of  Butlin's 
specimens  and  drawings  give  great  encouragement  in  the  treatment  of  cancer 
of  the  tongue  even  when  apparently  advanced: 

Analysis  of  the  seventy  cases  in  which  the  contents  of  the  anterior  triangle 
were  removed: 

Died  of  the  operation 6 

Lost  sight  of  after  operation i 

Died  of  recurrence  in  the  mouth 9 

Died  of  recurrence,  uncertain  where  (in  one  of  these  the  glands  could  not 

be  entirely  removed;  operation  abandoned) 7 

Died  of  recurrence  in  the  glands  (in  one  of  these  the  submaxillary  salivary 
gland  was  left  and  the  disease  recurred  beneath  it;  in  the  other  seven 
cases  the  glands  were  enlarged  at  the  time  of  their  removal,  and  in  five 

of  these  they  were  demonstrably  cancerous) 8 

Died  of  cancer  on  the  opposite  side  of  the  tongue i 

Died  of  affection  of  glands  on  opposite  side  of  neck 2 

Died  of  other  disease  within  three  years i 

Cases  not  countable  (operation  too  recent) 11 

Successful  cases 24 

Total 70 

The  successful  cases  are  calculated  on  the  seventy  cases,  after  deducting 
cases  not  countable  (n),  the  patient  who  died  within  three  years  of  another 
disease  (i),  and  the  patient  who  was  not  traced  after  the  operation  (i),  leaving 
fifty-seven  cases,  with  twenty-four  successful  cases  =42.01  per  cent. 

The  age  of  the  patients  operated  on  showed  that  ten  of  them  were  over 
65  years  of  age,  and  one  over  70  years  (77). 


148  TONGUE. 

The  causes  of  death  from  operation  were: 

Hemorrhage,  etc.  (both  from  mouth  and  neck  in  a  badly  alcohoHc  patient.  .  i 
Suffocation  (from  the  sudden  faUing  back  of  the  root  of  the  tongue  some 

days  after  operation) i 

Septic  pneumonia 4 

Total 6 

(B)  The  disease  involves  the  floor  of  the  mouth  to  such  an  extent  that  the 
intrabuccal  operation  is  impossible. 

Remove  the  tongue  by  any  of  the  methods  already  described,  and  according 
to  the  condition  of  the  patient  remove  the  glands  of  the  neck  either  at  the  same 
or  at  a  subsequent  seance. 

Whatever  operation  is  chosen  for  removal  of  lingual  cancer,  it  is  always 
of  prime  importance  to  remove  en  masse  the  whole  of  the  related  lymphatic 
territory,  even  if  the  primary  lesion  appear  trivial  and  the  lymphatics  show 
no  macroscopic  involvement. 

Crile  ("Journ.  Am.  Med.  Assoc,"  Dec.  i,  1906)  reports  remarkably 
favorable  results  from  an  operation  similar  to,  but  more  extensive  than  Butlin's. 
When  lymph  nodes  are  palpably  enlarged,  further  metastasis  is  sure  to  be 
irregular,  therefore  Crile  removes  the  whole  lymphatic-bearing  tissue  on  the 
affected  side;  when  there  are  no  palpably  enlarged  glands  he  only  removes  the 
lymphatics  next  in  order. 

In  operating  on  the  former  class  of  cases  Crile  temporarily  compresses 
the  common  carotid  with  his  special  clamp,  doubly  ligates  and  divides  the 
internal  jugular  vein  low  down  in  the  neck  and  excises  the  vein  along  %vith 
the  lymphatic  tissues,  and  the  muscles  of  that  side  of  the  neck  (Fig.  220). 

Maitland  ("The  Australasian  Med.  Gazette,"  Oct.  20,  1906)  describes  a 
thorough  operation  which  has  given  him  much  satisfaction  and  which  he 
practises  in  all  except  very  early  and  very  late  cases.  Fig.  221  shows  Maitland's 
incisions.  The  follovdng  paragraphs  are  copied  from  the  article  to  which 
reference  has  been  made. 

"  Dissection  of  the  Digastric  Triangle. — A  clean  dissection  is  then  made  of 
this  triangle,  beginning  at  the  point  of  the  chin  and  working  outwards  and 
upwards,  paying  particular  attention  to  the  spaces  between  the  outer  edge  of 
the  mylohyoid  and  the  hyoglossus,  as  glands  are  easily  overlooked  in  these 
situations.  The  anterior  layer  of  the  outer  portion  of  the  deep  cervical  fascia, 
which  here  forms  a  compartment  for  the  submaxillary  gland,  is  opened,  the 
glands  pulled  forwards,  the  facial  artery  tied  and  divided,  the  common  facial 
and  anterior  division  of  the  temporo-maxillary  veins  having  been  previously 
tied  and  divided.  The  dissection  of  this  anterior  portion  of  the  digastric 
triangle  is  then  completed  by  carrying  the  dissection  well  up  over  the  body  of 
the  mandible,  so  as  to  remove  the  lower  of  the  facial  glands.  That  portion  of 
the  digastric  triangle  posterior  to  the  stylo-maxillary  ligament  containing  the 
parotid  is  next  cleared  and  the  lower  portion  of  the  parotid  is  removed.     This 


CRILE  S    OPERATION. 


149 


Fig.  220. — (Crile.) 
The  entire  mass  of  lymphatic  gland  bearing  tissue  is  excised  en  bloc,  and  handled  as 
little  as  possible.  This  dissection  becomes  easy  when  followed  in  the  deep  plane.  The 
entire  block  of  tissue  is  finally  divided  above,  including  the  vein.  A,  splenius.  B,  hypo- 
glossus  descendens.  C,  spinal  accessory.  D,  elevator  ang.  scapuli.  E,  pneumogastric. 
F,  scalenus  posticus.  G,  internal  jugular.  H,  facial  vein  and  artery.  I,  submental.  J, 
submaxillary.  K,  digastric.  L,  mylohyoid.  M,  sternohyoid.  N,  omohyoid.  O,  thyroid 
gland.    P,  thyrohyoid.     Q,  carotid. 


I50 


TONGUE. 


dissection  is  carried  sufficiently  deep  to  remove  the  deep  parotid  glands;  this 
step  has  been  insisted  on  by  Butlin.  I  have  regularly  carried  it  out  for  some 
years. 

"Division  of  the  Sternomastoid. — Before  this  step  in  the  operation  is  per- 
formed the  dissection  of  the  anterior  triangle  is  begun  from  before  back- 
wards till  the  anterior  border  of  the  sternomastoid  is  reached.  This  muscle 
is  then  divided  at  the  level  of  the  omohyoid,  the  lower  portion  being  turned  down. 

"Dissection  oj  the  Anterior  and  Posterior  Triangles. — The  dissection  of  these 
two  triangles  is  then  proceeded  with  from  below  upwards,  cleaning  all  the 
fascia  off  the  vessels.  The  dissection  is  carried  on  right  up  beneath  the  parotid, 
the  dissection  being  completed  by  removing  the  sternomastoid  muscle  at  its 


Fig.  221. — ^Maitland  (Australasian  Med.  Gaz.) 


insertion,  together  with  the  contents  of  the  anterior  and  posterior  triangles. 
By  this  means  the  whole  of  the  deep  descending  cervical  chain  of  glands  is 
removed. 

"Removal  of  Internal  Jugular  Vein. — This  is  done  as  the  last  step  of  the 
operation;  if  it  be  done  earlier  in  the  operation  much  valuable  time  is  lost  in 
stopping  venous  hemorrhage.  I  am  firmly  of  opinion  that  only  by  removing 
the  sternomastoid  muscle  can  the  deep  cervical  chain  of  glands  be  thoroughly 
removed.  The  internal  jugular  vein  I  do  not  always  remove,  as  with  the 
removal  of  the  sternomastoid  muscle,  as  I  suggest,  the  vein  can  be  more  thor- 
oughly cleared  both  on  its  anterior  and  posterior  aspects. 

"The  Effect  of  Removal  of  the  Sternomastoid  Muscle. — All  the  movements 
of  the  head  are,  as  I  show  you  from  these  cases,  thoroughly  carried  out  by  the 
post-rotators,  and  the  removal  of  the  muscle  practically  in  no  wise  interferes 
with  the  head  movements.  The  text-books  advise  preservation  of  the  muscle, 
because  of  the  supposed  interference  with  the  movements  of  the  head;  but  this 
view  I  know  to  be  erroneous. 

"The  Division  of  the  Spinal  Accessory. — This  is  done  in  nearly  every  case, 
and  only  in  two  instances  have  I  seen  drooping  of  the  shoulders;  the  third  and 
fourth  cervical  are  sufficient  to  preserve  the  function  of  the  muscle." 

When  cancer  is  limited  to  the  base  of  the  tongue  near  the  epiglottis,  or 
when  it  affects  the  epiglottis,  Vallas'  operation  of  transhyoid  pharyngotomy 


VALLAS     OPERATIOISl.  I5I 

gives  good  access  to  the  parts.  This  operation  is  also  suitable  for  the  removal 
of  foreign  bodies  and  the  treatment  of  syphilitic  strictures.  Preliminary  trache- 
otomy is  not  essential. 

The  Operation. — Step  i. — Make  a  median  incision  through  the  skin  and 
subcutaneous  tissue  from  the  symphysis  of  the  lower  jaw  to  the  superior  angle 
of  the  thyroid  cartilage. 

%tep  2. — With  blunt  or  sharp  dissection  separate,  in  the  middle  line,  the 
fibres  of  the  mylohyoid  muscles  in  such  fashion  as  to  expose  the  upper  border 
of  the  hyoid  bone  in  the  median  line. 

Step  3. — With  scissors  or  bone  forceps  divide  the  hyoid  bone  in  the  middle 
line.  Retract  the  halves  of  the  bone  along  with  the  fibres  of  the  mylohyoid 
muscle.     This  gives  us  a  space  i   1/2  inches  in  width. 

Sept  4. — The  lower  part  of  the  wound  is  separated  from  the  pharynx  by  the 
thyrohyoid  membrane,  the  upper  part  by  the  mucosa.  To  reach  the  pharynx, 
divide  the  thyrohyoid  membrane;  to  reach  the  base  of  the  tongue  or  floor  of  the 
mouth,  cut  upwards.  Access  has  now  been  gained  to  the  seat  of  the  disease. 
It  is  unnecessary  here  to  describe  over  again  the  removal  of  the  neoplasm; 
it  must  be  done  freely  on  the  principles  already  enunciated.  Having  completed 
the  excision,  close  the  wound,  providing  drainage  at  its  lower  end.  No  special 
suture  of  the  hyoid  bone  is  required. 


CHAPTER  XVI. 

PAROTID  GLAND. 

From  the  standpoint  of  operative  surgery  tumors  of  the  parotid  may  be 
divided  into  two  classes: 

1.  Those  which  are  encapsulated  inside  the  gland.  This  encapsulation 
may  not  be  perfect,  but  there  is  no  general  infiltration  of  the  gland  by  the  disease. 
Such  tumors  are  the  adenomata  and  the  mixed  tumors  of  feeble  malignancy. 

2.  Those  tumors  which  infiltrate  the  gland  substance.  Such  are  the  sar- 
comata and  carcinomata. 

The  principles  of  operation  which  may  be  applied  to  both  classes  of  tumors 
alike  are:  (a)  Early  operation;  {b)  free  exposure  of  the  growth  by  suitable 
incisions;  (c)  careful  hemostasis. 

When  the  tumor  is  one  of  those  encapsulated  within  the  gland,  it  should, 
if  possible,  be  enucleated  with  its  capsule,  leaving  the  gland  as  little  injured 
as  is  practicable.  When  the  capsule  cannot  be  removed  with  the  growth,  it 
should  be  removed  afterwards  as  thoroughly  as  circumstances  permit.  The 
facial  nerve  must  be  preserved.  An  incomplete  operation  often  gives  good 
results,  but  completeness  must  always  be  the  aim.  When  the  tumor  is  of  the 
infiltrating  type,  the  whole  gland  with  its  fascial  coverings  or  capsule  must  be 
removed,  and  with  it  any  adherent  skin.  Little  attention  may  be  given  to  the 
facial  nerve;  its  destruction  is  almost  certain.  T.  Carwardine  and  Gunn  have 
each  preserved  the  facial  nerve  in  such  operations.  The  necessary  dissection 
must  take  very  much  time  and  in  feeble  patients  this  constitutes  no  mean 
risk.  As  in  the  case  of  cancers  located  elsewhere,  too  much  rather  than  too 
little  must  be  done.  If  the  surgeon  believes  that  the  whole  growth  cannot 
be  removed,  it  is  better  to  abstain  from  operation.  An  incomplete  operation 
is  worse  than  useless. 

I.  Enucleation  of  Parotid  Tumors. — (A)  The  tumor  is  small,  mobile, 
and  apparently  easily  removed:  Make  a  horizontal  incision  over  the  promi- 
nent portion  of  the  growth,  parallel  to  the  course  of  the  fibres  of  the  facial  nerve 
and  of  length  sufficient  to  permit  of  removal  of  the  tumor  under  guidance  of 
the  eye  and  without  bruising  of  the  wound.  Incise  the  gland  substance  so  as 
to  expose  the  tumor,  which  must  now  be  shelled  out.  Attend  to  hemostasis; 
in  doing  this,  suture-ligatures  involving  the  gland  substance  should  be  avoided, 
as  they  are  liable  to  constrict  branches  of  the  facial  nerve  and  salivary  ducts. 
Close  the  wound  with  or  without  drainage. 

(B)  The  tumor  is  not  large  and  not  suitable  for  the  simple  procedure  described 
above: 

152 


PAROTID   TUMORS.  1 53 

Step  I. — Beginning  at  the  tip  of  the  mastoid  process,  make  an  incision 
downwards  along  the  anterior  edge  of  the  sternomastoid,  to  the  level  of  the 
angle  of  the  lower  jaw;  from  this  point  cut  forwards  and  upwards,  in  a  curve, 
over  the  ascending  ramus  of  the  jaw,  until  a  flap  is  outlined  which  when  elevated 
will  expose  most  of  the  tumor.  The  flap  consists  of  skin  and  superficial 
fascia  alone;  no  deeper  structures  must  be  involved  because  of  the  facial 
nerve. 

Step  2. — The  growth  of  the  tumor  inevitably  pushes  aside  and  spreads 
out  the  glandular  tissue  in  which  it  lies.  Examine  the  exposed  surface  for 
that  part  least  covered  by  glandular  tissue.  The  tumor  capsule  will  generally 
be  seen  at  once;  if  not,  expose  it  by  dividing  horizontally  any  overlying  glandular 
substance.  If  the  capsule  is  strong,  proceed  to  do  an  extracapsular  enucleation 
by  blunt  dissection.  Any  bands  of  tissue  passing  to  the  capsule  from  its 
surrounding  must  be  doubly  ligated  and  divided.  First  free  the  anterior 
border  of  the  tumor,  then  the  posterior,  and  dissect  free  its  deep  surface /row 
below  upwards  so  as  to  gain  early  control  of  the  vascular  supply.  Proceeding 
in  this  fashion,  it  is  often  possible  to  enucleate  the  tumor  en  masse,  but  often 
enough  some  deeply  seated  fragments  are  left  behind;  such  must  now  be  re- 
moved individually. 

If  the  capsule  is  weak  and  the  tumor  soft,  extracapsular  enucleation  is  im- 
possible. Under  these  circumstances  freely  incise  the  capsule,  clean  out  its 
contents,  and  remove  the  capsule  bit  by  bit  as  thoroughly  as  possible.  This 
apparently  very  imperfect  operation  often  gives  excellent  results.  With 
regard  to  enchondromata  of  the  salivary  glands  Jacobson  writes:  "It  is  not 
uncommon  for  branches  of  the  facial  ner\'e  to  be  in  relation  with  the  capsule  of 
the  tumor,  and  if  this  had  been  much  handled,  or  treated  by  counter-irritation, 
they  may  very  likely  be  firmly  adherent.  In  either  case  injury  to  the  nerve  may 
be  best  avoided  by  slitting  up  the  capsule  and  shelling  out  the  enchondroma 
first.  The  capsule  should  then  be  examined  to  see  if  any  nerve  branches  are 
adherent  to  it;  after  these  have  been  separated,  the  capsule  itself  should  be 
removed.  This  should  always  be  done  to  prevent  any  recurrence,  as  the  per- 
ipheral part  of  these  encondromata  is  often  adherent  to  the  capsule  itself." 
("Operations  of  Surgery,"  I,  340.) 

Step  3. — Attend  to  heraostasis.  Close  the  wound  by  sutures.  Drain  dead 
spaces.     Dress. 

II.  Excision  of  the  Parotid. — Excision  of  the  parotid  is  necessary  in 
cases  of  malignant  neoplasms,  such  as  carcinoma  or  sarcoma.  As  these 
tumors  are  infiltrating  in  character,  enucleation  is  impossible  and  useless;  the 
whole  gland  must  be  removed,  whether  evidendy  affected  or  not. 

Step  I. — Make  a  | — shaped  incision  (Fig.  222)  of  sufficient  extent,  through 
the  skin.     Reflect  the  skin  so  as  to  expose  all  the  parotid  covered  by  its  fascia. 

Step  2. — Mobilize  the  anterior  edge  of  the  gland  and  tumor.  Doubly 
ligate  and  divide  the  vessels  situated  here  and  Steno's  duct.  Forceps  may  be 
used  instead  of  ligatures  during  the  dissection.     Separate  the  gland  from  the 


154  PAROTID    GLAND. 

masseter,  working  from  before  backwards,  doubly  ligating  all  vessels  before 
dividing  them. 

Step  3. — Separate  the  lower  edge  of  the  gland  (submaxillary  portion)  from 
its  surroundings  by  blunt  dissection,  doubly  ligating  and  dividing  the  vessels. 

Step  4. — Expose  the  upper  end  of  the  anterior  portion  of  the  sternomastoid, 
open  its  sheath,  and  retract  the  muscle  backwards.  That  portion  of  the  sheath 
adherent  to  the  fascia  covering  the  parotid  must  be  removed  with  the  tumor. 

Step  5. — By  blunt  dissection,  working  from  below  upwards  and  elevating  the 

lower  edge  of  the  gland,  expose  the  external  carotid  artery  as  it  passes  under  the 

^^____.^^  stylohyoid  and  digastric   muscles.      Doubly   tie   and 

/"'^  >.       divide  the  artery.     Mobilize  the  tumor  and  gland  up 

/  \    to  the  level  of  the  styloid  process. 

I  ^fc^^  I         Step  6. — Separate  by  blunt  dissection  all  connec- 

)  ^^^        1^         /    tions  between  the  tumor  and  the  temporo-maxillary 

/  \Wj       J     joint.     Ligate  and  divide  the  temporal  vessels  at  the 

4.  ]K     /         level  of  the  zygoma. 

Si^  y        \  Step  7. — Pull  the  gland,  etc.,  backwards,  expose  the 

V     ^^^'^^^  \     numerous  veins  which  run  along  with  the   internal 

j-  \    maxillary  artery,  from  behind  the  neck  of  the  lower 

Pjq    222  i^^  ^^^°  ^^^  gland.     Doubly  ligate  this  leash  of  vessels 

and  divide  them. 

Step  8. — Separate  by  blunt  dissection  the  posterior  and  pharyngeal  connec- 
tions of  the  gland,  doubly  ligating  or  clamping  all  vessels  before  dividing  them. 
In  making  this  last  dissection  be  on  the  lookout  for  and  avoid  injury  to  the 
internal  jugular  vein. 

Step  g. — Attend  to  hemostasis.  Close  the  wound  with  sutures  after  provid- 
ing for  drainage. 

Any  enlarged  lymphatic  glands  near  the  parotid  ought  to  be  removed  along 
with  the  tumor.  The  operation  is  a  difficult  one,  and  ought  not  to  be  attempted 
by  the  inexperienced. 

Salivary  Fistula. — A  salivary  fistula  most  commonly  results  from  disease 
or  injury  of  Steno's  duct.  In  some  cases  a  stricture  is  present  distal  to  the 
fistula,  and  if  this  is  dilated,  the  fistula  either  closes  spontaneously  or  after  its 
orifice  has  been  stimulated  by  the  cautery  or  revivified  and  sutured.  When 
the  above  simple  treatment  is  inappropriate  or  has  failed,  operation  becomes 
necessary. 

I.  The  fistula  is  anterior  to  the  masseter  muscle. 

(A)  Von  Lzngenbeck's  Operation. — Make  the  proximal  portion  of  the  duct 
(i.  e.,  the  segment  of  duct  next  to  the  parotid  gland)  prominent  by  passing  a 
probe  into  it,  through  the  fistula.  With  a  knife  or  scissors  separate  the  fistula 
and  duct  from  their  surroundings,  leaving  them  attached  to  the  gland.  In  a 
convenient  location  pass  the  knife  from  the  wound  into  the  mouth,  perforating 
the  buccal  mucosa.  Pull  the  free  end  of  the  mobilized  duct  into  the  mouth 
through  the  perforation  in  the  mucosa  and  fix  it  there  with  sutures.     Close  the 


SALIVARY    FISTULA.  155 

external  wound.  When  applicable,  the  above  is  the  best  operation  for  salivary 
fistula,  but  unfortunately  it  is  not  often  available,  as  the  unnatural  orifice  is 
usually  far  back  near  the  origin  of  Steno's  duct  behind  the  anterior  margin  of 
the  masseter. 

(B)  Deguise's  Operation. — From  the  fistula  make  two  perforations  into  the 
mouth,  about  1/4  inch  apart.  Through  these  openings  pass  the  two  ends  of  an 
elastic  ligature,  a  piece  of  lead  wire,  or  a  stout  silk  suture.     Fasten  together 


Surface 


Fig.  223. 

the  ends  of  the  ligature  in  the  mouth  so  as  to  exercise  pressure  on  the  included 
tissues.  Necrosis  of  the  tissues  follows  and  a  permanent  opening  into  the 
mouth  is  assured.  Freshen  the  edges  of  the  cutaneous  fistula  and  unite  them 
by  sutures.  The  elastic  ligature  or  lead  wire  may  best  be  introduced  through  a 
cannula  which  is  made  to  perforate  the  cheek  from  within  outwards  (Figs.  223, 
224).  A  silk  suture  is  best  inserted  from  without  inwards  by  means  of  a  needle 
at  each  end. 

(C)  Kaufmann'' s  Operation. — Pass  a  cannula  (about  1/8  inch  in  diameter) 
from  the  fistula  into  the  mouth  and  through  it  introduce  a  rubber  tube  or  seton. 


Fig.  225. 

Remove  the  cannula,  leaving  the  seton  in  place.  Whenever  the  track  of  the 
seton  has  become  covered  with  epithelium,  remove  the  seton  and  close  the 
cutaneous  orifice  of  the  fistula. 

II.  The  fistula  is  situated  in  the  masseteric  portion  of  Steno's  duct. 

(A)  Either  Kaufmann's  seton  or  Deguise's  method  of  double  puncture  may 
be  used,  but  neither  the  seton  nor  the  constricting  ligature  must  perforate  the 
masseter.  The  puncture  or  punctures  must  pass  from  the  fistula  to  the  mouth 
by  tunnelling  between  the  masseter  and  the  skin. 


156 


PAROTID   GLAND, 


(B)  Von  Langenbeck's  method  may  be  used  if  a  sufficient  length  of  duct 
remains  attached  to  the  gland.  In  this  method  it  is  necessary  to  puncture  the 
masseter  and  pull  the  mobilized  portion  of  duct  through  the  puncture  into  the 
mouth.  Instead  of  being  punctured,  the  masseter  may  be  divided  transversely, 
and  if  necessary  a  portion  of  the  ascending  ramus  of  the  lower  jaw  may  be  cut 
away  with  rongeurs  so  that  the  defective  duct  may  gain  access  to  the  mouth. 


Fig.  226. 


(C)  Plastic  formation  of  a  new  duct  (Braun's  operation) :  Make  the  incision 
A,  B  (Fig.  225).  Mobilize  the  fistulous  orifice  by  dissecting  it  free  from  the  skin. 
The  incision  penetrates  all  the  tissues  of  the  cheek  except  the  mucosa  and 
masseter.     Retract  the  edges  of  the  wound,  exposing  the  outer  surface  of  the 


Fig. 


mucosa  (Fig.  226).  From  the  mucosa  construct  a  flap  with  its  pedicle  at  the 
edge  of  the  masseter,  of  length  sufficient  to  reach  from  the  masseteric  edge  to  the 
fistula.  Turn  this  flap  back  over  the  masseter;  suture  its  free  end  to  the  fistula; 
suture  its  upper  and  lower  edges  together  so  as  to  form  a  tube  lined  with  epithe- 
lium (Fig.  227).     Close  the  skin- wound. 


CHAPTER  XVII. 

OPERATIONS  UPON  THE  NOSE. 

EXCISION  OF  INTRANASAL  MALIGNANT  TUMORS. 

DENKER'S  TRANSMAXILLARY  METHOD.* 

Step  I. — With  blunt  hooks  pull  the  angle  of  the  mouth  and  the  upper  lip 
upwards  and  outwards.  Beginning  opposite  the  wisdom  tooth  on  the  affected 
side  make  an  incision  through  the  gum  of  the  upper  jaw  to  a  point  near  the  fre- 
num  of  the  upper  lip.  The  incision  should  be  slightly  curved  upwards.  With 
an  elevator  separate  the  soft  parts  from  the  upper  jaw  until  that  bone  is  exposed 
nearly  to  the  lower  margin  of  the  orbit  and  the  pyriform  aperture  of  the  nose  is 
laid  bare. 

Step  2. — With  a  fine  elevator  or  dissector,  beginning  at  the  pyriform  aperture, 
separate  the  mucous  membrane  from  the  outer  wall  of  the  lower  and  middle 
sinuses  of  the  nose  and  pardy  from  the  floor  of  the  nose.  Continue  this  separa- 
tion backwards  to  the  posterior  limits  of  the  antrum  of  Highmore.  If  the  lower 
turbinated  bone  is  not  involved  in  the  tumor,  remove  it  with  strong  scissors. 
Temporarily  pack  with  gauze  for  hemostasis. 

Step  3. — With  chisel  and  rongeur  remove  the  external  bony  wall  of 
the  antrum  of  Highmore.  If  the  mucosa  lining  the  interior  surface  of  this 
wall  is  healthy  incise  it  freely  so  as  to  grain  free  access  to  the  sinus ;  if  it  is  in- 
volved in  the  growth,  extirpate  it  with  the  growth.  With  chisel  and  rongeur 
remove  completely  the  inner  or  nasal  wall  of  the  antrum,  both  the  bone  and  the 
mucosa. 

Step  4. — With  scissors  or  probe-pointed  knife  remove  the  mucosa  of  the 
outer  wall  of  the  nose  (already  separated  in  Step  2).  If  the  tumor  has  arisen 
from  the  middle  sinus  of  the  nose  it  generally  will  come  away  with  the  nasal 
mucous  membrane.  Free  access  is  now  attained  to  the  ethmoidal  and  sphenoi- 
dal sinuses  which  can  be  treated  according  to  circumstances. 

Step  5. — Pack  the  wound  with  gauze.  Suture  the  oral  wound.  Keep  the 
mouth  clean  with  washes.     Remove  the  pack  after  three  or  four  days. 

The  above  operation  is  not  suitable  for  cases  of  tumors  arising  from  the 
nasopharynx,  retro-maxillary  or  pterygo-palatine  fossae. 

RHINOPHYMA  (ACNE  HYPERTROPHICA). 

This  deforming  disease  must  be  treated  by  operation.  If  the  tumors  are 
pedunculated  their  removal  requires  no  special  description,  if  they  are  extensive 
and  non-pedunculated  proceed  as  follows: 

*  "Miinchener  med.  Wochenschrift,  1906,  No.  20. 


158 


OPERATIONS    UPON   THE   NOSE. 


Give  a  general  anaesthetic. 

Step  I. — Through  the  anterior  nares  introduce  gauze  strips  and  so  plug  the 
posterior  two-thirds  of  the  nose,  leaving  the  anterior  portion  free.  This  prevents 
the  inllow^  of  blood.     Plugging  of  the  posterior  nares  will  do  as  well. 

Step  2. — Put  the  forefinger  of  the  left  hand  into  one  nostril  as  a  guide.  Make 
an  incision  down  to  but  not  into  the  cartilage,  all  round  the  growth  from  the 
middle  line  outward  (Fig.  228). 

Be  sure  to  leave  as  much  skin  as  possible  near  the  opening  of  the  nares  to 
avoid  subsequent  stricture. 


Fig.  228. — (Laurens.) 


Fig.  229. — {Laurens.) 


Step  3. — Seize  the  median  edge  of  the  tumor  mass  with  forceps  and  entrust 
these  to  the  assistant  (Fig.  229).  With  knife  or  scissors  shave  off  all  the  dis- 
eased tissues  within  the  circle  of  the  incision.  Attend  to  hemostasis  with 
forceps,  ligature,  pressure  with  hot  pads  or  the  thermo-cautery. 

Step  4. — Repeat  Steps  3  and  4  on  the  opposite  side. 

Step  5. — Remove  the  nasal  plugs.  Introduce  short  drainage  tubes  into  each 
nostril.  Cover  the  wounds  with  rubber  tissue,  perforated  oiled  silk  or  silver 
foil.  Apply  compressive  dressings.  The  results  in  time  are  very  good.  Skin 
grafting  is  rarely  necessary. 


RHINOPLASTY. 

Rhinoplasty,  or  the  reconstruction  of  the  nose,  is  called  for  in  cases  where 
the  nose  has  been  destroyed  by  disease  or  operation.  The  character  of  the 
operative  interference  required  varies  with  the  location  and  extent  of  tissue 
destruction. 

I.  The  destruction  is  confined  to  the  soft  structures  of  the  nose  but  the 
osseous  and  a  part  of  the  soft  structures  of  the  nose  remain. 


RHINOPLASTY. 


159 


A,  A  relatively  small  portion  of  the  soft  parts  has  been  destroyed.  Figs. 
230,  231,  232,  233  sufi&ciently  explain  the  correction  of  this  defect. 

1.  The  defect  is  confined  to  one  ala.  Fritz  Konig  ("Berlin,  klin.  Woch.," 
1902,  No.  7),  after  thoroughly  freshening  the  nasal  defect,  implanted  into  it  a 
properly  shaped  segment  consisting  of  the  whole  thickness  of  the  concha  of  the 
ear.     The  result  was  excellent. 

2.  The  defect  extends  beyond  the  ala  but  is  still   lateral. 


Fig.  230.  Fig.  231.  Fig.  232.  Fig.  233. 

Figs.  230,  231,  232  and  233. — {Esmarch  and  Kowakig.) 


Fig.  234. 

Figs.  234,  235,  and  236. 


Fig.  235. 
-{Esmarch  and  Kowalzig.) 


Fig.  236. 


Langenbeck's  Operation. — From  the  sound  side  of  the  nose  retiect  a  skin- 
flap,  which  has  its  base  near  the  inner  angle  of  the  eye  of  the  affected  side 
(Figs.  234  and  235).  Suture  the  flap  thus  obtained  to  the  edges  of  the  defect, 
which  have,  of  course,  been  vivified  immediately  before.  Cover  the  raw  surface 
left  by  the  elevation  of  the  flap  with  Thiersch's  skin-grafts. 

Nelaton's  Operation. — This  is  similar  to  the  preceding,  but  the  flap  is 
obtained  from  the  cheek  (Fig.  236). 

3.  The  septum  is  absent. 

Diefifenbach's  Operation. — Make  a  flap  as  outlined  in  Fig.  237,  consist- 
ing of  the  whole  thickness  of  the  upper  lip.  Freshen  the  distal  end  of  the  flap, 
turn  it  forwards,  and  suture  it  to  a  vivified  area  on  the  anterior  edge  of  the 
nasal  opening  (Fig.  238).     Close  the  wound  in  the  lip. 


i6o 


RHINOPLASTY. 


Fig.  237.  Fig.  238. 

Figs.  23;  and  2 2,^. ^{Es march  and  Kowalzig.) 


Fig.  239.  Fig.  240. 

Figs.  239  and  240. — {Esmarch  and  Kowalzig.) 


Fig.  241. 


Fig.  242. 


RHINOPLASTY. 


l6l 


Langenbeck  makes  a  flap  from  the  skin  of  the  upper  lip,  leaving  the  deeper 
structures  intact  (Figs.  239  and  240). 

Both  of  the  above  methods  are  faulty  in  that  use  is  made  of  very  hairy 
skin,  and  annoyance  is  sure  to  result. 

Lexer  makes  a  flap  from  the  mucous  and  submucous  structures  of  the  upper 
lip,  leaving  the  skin  intact  except  for  a  perforation  through  which  the  flap  is 
brought  into  position  (Figs.  241  and  242). 


Fig.  243  Fig.  244 

Fig.  243  AND  244. — {Esmarch  and  Kowalzig.) 

Hueter  uses  a  flap  of  skin  obtained  from  the  nose  itself  (Figs.  243  and  244). 

B.  Practically  all  the  soft  structures  of  the  nose  are  absent. 

I.  Indian  Methods. — In  this  operation  a  pedunculated  flap  is  taken  from 
the  forehead  and  sutured  to   the  nasal   defect. 

The  Operation. — With  oiled  silk  make  a  model  of  the  flap  required.  Figs. 
245  to  252  represent  variously  shaped  flaps  which  have  been  used. 


Fig.  245. 


Fig.  246 


Fig.  247. 


Fig.  2z 


Fig.  249.  Fig.  250.        Fig.  251.  Fig.  252. 

Figs.  245  to  252. — (Esmarch  and  Kowalzig.) 

"  Step  I. — Place  the  anesthetized  patient  in  the  Rose  or  Trendelenburg  posture. 
Thoroughly  freshen  the  edges  of  the  nasal  defect  down  to,  but  not  beyond,  the 
points  into  which  the  new  alae  of  the  nose  are  to  be  inserted.  When  consider- 
able skin  exists  over  the  bridge  of  the  nose,  Step  i  may  be  modified  advantage- 
ously as  follows:  From  the  nasal  bridge  reflect  the  flap  of  skin  A,  B,  C  (Fig. 
254)  and  turn  it  down  with  its  epidermal  surface  directed  towards  the  nasal 


l62 


OPERATIONS   UPON   THE   NOSE. 


cavity.  Freshen  or  pare  the  edges  of  the  nasal  defect  as  already  described 
When  in  Step  3  the  forehead  flap  is  turned  down,  its  raw  surface  lies  in 
contact  with  the  raw  surface  of  the  flap  from  the  nasal  bridge,  an  epidermal 
lining  is  provided  for  the  new  nose,  and  thus  shrinking  is  obviated. 


Fig.  253. — {Esniarch  and  Kowalzig.) 


Fig.  254. 


Fig.  255. 


Fig.  256. — {Esmarch  and  Kowalzig.) 


Step  2. — Place  the  oiled  silk  model  on  to  the  forehead,  in  an  oblique  position, 
and  with  its  pedicle  so  placed  as  to  include  the  angular  artery.  Guided 
by  the  model  as  to  shape  and  size,  cut  a  flap  from  the  forehead.  The  flap  con- 
sists of  all  the  structures  down  to  the  bone.  With  sutures  lessen  the  size  of 
the  defect  left  in  the  forehead;  cover  such  open  wound  as  may  be  left  with 
skin-grafts. 

*  In  Fig.  256  the  flap  has  been  taken  from  a  different  part  of  the  fore-head. 


RHINOPLASTY. 


163 


Step  3. — Turn  the  forehead  flap  downwards  with  its  epidermal  surface  for- 
wards, being  careful  not  to  twist  the  pedicle  too  severely.  As  this  step  is  being 
carried  out  it  may  be  necessary  to  lengthen  the  lateral  incisions  which  bound 
the  pedicle.  Fig.  253  shows  a  well-designed  pedicle.  Attention  to  the 
pedicle  is  of  prime  importance  because  too  great  torsion  means  interference 
with  the  blood-supply,  and  more  particularly  with  the  drainage  of  the  flap.  It 
is  wise  to  make  numerous  shallow  scratches  through  the  epidermis  of  the  flap; 
these  permit  of  lymphatic  drainage.  (See  chapter  on  Plastic  Operations.) 
Fold  on  itself,  laterally,  that  portion  of  the  flap  which  is  to  form  the  new  septum 
of  the  nares  and  maintain  this  fold  by  one  or  two  stitches  (Fig.  255).  Fold 
on  themselves  the  two  lower  angles  of  the  flap  which  are  to  form  the  alae  of,  the 
nose  and  maintain  the  folds  by  means  of  mattress  sutures. 

Step  4. — Suture  the  raw  edges  of  the  new  alas  of  the  nose  into  their  proper 
position  in  the  nasal  defect.     Do  the  same  with  the  new  nasal  septum.     Suture 


Fig.  257.  Fig.  258. 

Figs.  257  and  258. — (Monod  and  Vanverts.) 


the  rest  of  the  flap  in  position  (Fig.  256).  Do  not  use  too  many  sutures  near 
the  pedicle,  and  in  attempts  at  esthetic  efi"ect  do  not  jeopardize  the  vitality  of 
the  flap,  which  depends  on  the  freedom  of  the  pedicle.  If  the  flap  lives  and 
unites  in  its  new  position,  any  defects  in  the  appearance  of  the  root  of  the  nose 
may  be  safely  attended  to  subsequently.  Keep  the  newly  formed  nasal  open- 
ings patent  by  means  of  dressed  rubber  tubes  or  cigarette  drains. 

2.  French  Method. — In  this  operation  pedunculated  flaps  taken  from  the 
cheeks  are  used  to  repair  nasal  defect.  Figs.  257  and  258  suflaciently  describe 
the  operation  as  performed  by  Nelaton. 

3.  Italian  Method. — Skin  for  the  repair  of  the  nasal  defect  is  obtained 
from  the  anterior  and  inner  aspects  of  the  upper  arm. 

Step  I. — Dissect  from  the  upper  arm  a  flap  of  skin,  with  its  pedicle  pointing 
towards  the  elbow.  Flex  the  shoulder  and  bring  the  free  end  of  the  flap  in^ 
contact  with  the  vivified  edges  of  the  nasal  defect.  Unite  the  flap  to  the  nasal 
defect  by  means  of  sutures.     With  suitable  apparatus  (Fig.  259)  fix  the  head' 


1 64 


OPERATIONS    UPON    THE    NOSE. 


and  arm  so  that  they  maintain  a  constant  relationship  to  each  other  until  union 
has  taken  place. 

Step  2. — When  the  flap  is  firmly  united  to  the  edges  of  the  nasal  defect, 
divide  its  pedicle  and  complete  the  rhinoplasty  by  forming  the  ate  and  septum 
of  the  nose  out  of  the  lower  portion  of  the  flap. 

This  Italian  method  is  exceedingly  cumbersome,  and  few  patients  would 
endure  the  suffering  incident  to  its  completion.  . 

II.  The  destruction  of  tissue  involves  both  the  soft  parts  and  the  osseous 
and  cartilaginous  supports  of  the  nose. 

A.  The  tip  of  the  nose  with  its  alae  and 
septum  are  intact  [Konig  (see  p.  171), 
Israel  (see  p.  172).] 

B.  The  tip  of  the  nose  has  been  de- 
stroyed. 

Nelaton's  Operation. — Ch.  Nelaton 
has  devised  an  ingenious  method  of  rhino- 
plasty which  requires  no  description  other 
than  that  afforded  by  Figs.  260,  261,262,  263. 
Ch.  Nelaton's  Operation  with  Trans- 
plantation of  Costal  Cartilage.— PreZ/m/- 
nary  Operation. — S/e/?  i. — With  oiled  silk 
make  a  model  or  pattern  of  the  flap  neces- 
sary to  cover  the  new  nose  with  skin.  Lay 
the  model  on  the  forehead  and  mark  its  out- 
lines with  silver  nitrate.  The  best  shape  and 
position  for  the  flap  are  shown  in  Fig.  264. 
Step  2.— Without  injuring  the  perichondrium  excise  by  sharp  dissection 
the  whole  cartilage  of  the  eighth  rib.  Close  the  wound.  With  a  knife  pare 
about  one  inch  of  one  end  of  the  cartilage  (the  rib  end)  until  it  is  not  more  than 
1/8  inch  (3  mm.)  thick.  This  thin  portion  is  destined  to  form  the  new  column 
of  the  nose.  Where  the  pared  portion  of  cartilage  joins  the  unpared  portion 
cut  a  notch  nearly  through  the  cartilage  so  that  it  may  later  be  bent  in  fashion- 
ing the  nose. 

Step  3. — At  the  middle  of  the  distal  end  of  the  flap  outlined  with  silver 
nitrate  on  the  forehead,  make  a  cut  down  to  the  bone.  With  a  director  burrow 
a  tunnel  under  the  periosteum  from  end  to  end  of  the  flap  (Fig.  264).  Pass 
the  graft  of  cartilage  into  this  tunnel  in  such  fashion  that  its  thin  or  pared 
end  lies  subperiosteally  near  the  skin  wound  and  the  notch  at  the  junction  of 
the  pared  and  unpared  portions  faces  towards  the  skin.  Close  the  skin  wound. 
Apply  dressings. 

After  about  two  months  the  second  stage  of  the  operation  may  be  under- 
taken. 

Second  Stage  in  the  Operation. — Step  i. — Make  an  incision  all  round  the 
nasal  defect  except  at  its  lower  side  (Fig.  264).     This  cut  penetrates  to  the 


Fig.  25Q. — {Monod  and  Vanverts.) 


RHINOPLASTY. 


165 


bone.     Reflect  the  soft  parts  between  the  incision  and  the  nasal  defect  towards 
the  latter  (Fig.  264). 

Step  2. — Reflect  the  flap  which  was  outlined  on  the  forehead  at  the  prelimi- 
nary  operation.     (Of   course  the  original  marking  has  disappeared  but  the 


I'lG.  260.  Fig.  261. 

Figs.  260  and  261. — {Monod  and  Vanverts.) 


''if:' 


Fig.  262.  Fig.  263. 

Figs    262  and  263. — {Monod  and  Vanverts.) 

model  has  been  kept  and  the  flap  has  been  again  traced  out  with  silver  nitrate.) 
The  implanted  cartilage  is  an  integral  part  of  the  flap.  Model  the  distal  end 
of  the  flap  as  in  Figs.  255  and  265.  Gently  twist  the  flap  into  position  and 
fi.x  it  by  sutures  as  shown  in  Fig.  256.* 

*In  Fig.  256  the  flap  has  been  taken  from  a  different  part  of  the  forehead. 


i66 


OPERA.TIONS    UPON   THE   NOSE. 


Schimmelbusch's  Operation. — Practically  as  in  the  Indian  method, 
make  a  forehead  flap  to  cover  the  defect  in  the  nose,  but  here  the  flap  consists 
of  the  outer  table  of  the  skull  as  well  as  skin  (Fig.  266).  Protect  the  flap 
with  gauze  and  close  the  forehead  defect,  preferably  by  sliding  forwards  and 
inwards  large  flaps  of  the  scalp,  as  shown  in  Figs.  266  and  267.  Examine  the 
reflected  flap  of  bone  and  skin.  If  the  bone  is  not  splintered,  cover  the  whole 
raw  surface  at  once  with  Thiersch's  grafts,  protect  the  grafts  with  silver-foil 


Fig.  264. — {Laurens.) 


Fig.  265. — {Laurens.) 


Fig.  266. 


Fig.  267. 


or  rubber  tissue,  and  apply  gauze  dressings.  With  bandages  support  the 
flap  against  the  head  and  wait  until  the  grafts  have  become  mature.  This 
period  of  waiting  is  of  value  in -that  the  flap  becomes  accustomed  to  receiv- 
ing its  nourishment  through  the  pedicle  before  the  pedicle  is  disturbed  by 
twisting,  but  as  the  flap  inevitably  shrinks  during  the  delay,  it  is  very  neces- 
sary that  it  be  made  at  least  one-sixth  larger  than  the  defect  to  be  filled.  If 
on  examination  the  bone  in  the  flap  is  found  to  be  splintered,  delay  the  skin 
grafting  until  any  necrotic  bone  is  thrown  off  and  the  remainder  is  covered 


RHINOPLASTY.  1 67 

by  granulations  (four  to  eight  weeks).  When  the  raw  surface  of  the  flap  is 
satisfactorily  covered  with  epidermis,  making  an  incision  with  a  fine  saw  in 
the  middle  line  through  the  bone  in  the  flap,  so  that  the  flap  can  now  be  bent 
into  a  A  shape  (Fig.  267).  Mobilize  the  pedicle  of  the  flap  and  twist  the 
latter  into  position.  With  sutures  unite  the  edges  of  the  flap  to  the  freshened 
edges  of  the  nasal  defect.  When  freshening  the  edges  of  the  nasal  defect,  it  is 
easy  to  form  flaps  of  tissue  which  may  be  used  to  form  a  septum  for  the 
nostril  (Fig.  268). 

E.  Lexer's  Operation. — As  Schimmelbusch's  operation  is  based  on  Konig's 
so  is  Lexer's  on  Schimmelbusch's.  Lexer  ("  Archiv  fiir  klin.  Chir.,"  xcii,  749) 
recognizes  that  after  complete  rhinoplasty  it  is  most  diflfi- 
cult  to  breath  through  the  nose  because  of  contraction  of 
scar  tissue.  Before  operation  the  disease  causing  the 
deformity  (syphilis,  tuberculosis)  has  caused  much  de- 
struction of  tissue  and  recovery  has  taken  place  by  the 
filling  in  of  ulcerations  and  defects  with  granulation  tissue 
which  has  contracted  until  the  pyriform  opening  has  be- 
come small  and  distorted  and  nasal  respiration  is  poor. 
Before  attempting  to  form  a  new  external  nose  the  freedom 
of  the  air  passage  must  be  assured.  The  operation  is 
performed  in  many  stages.  P        ^o 

First  Stage. — Step  1. — With  knife,  scissors  and  chisel 
cut  away  all  scar  tissue  which  deforms  the  pyriform  opening  and  obstructs 
respiration. 

Step  2. — From  the  skin  around  the  opening,  from  remnants  of  the  alae 
of  the  nose,  etc.,  form  pedunculated  flaps  and  with  these  cover  the  defects 
resulting  from  the  excision  of  scar  tissue  (Fig.  269).  These  flaps  may  be 
held  in  place  by  gauze  tampons  until  they  become  united  to  their  new  beds. 
No  flaps  may  be  taken  from  the  root  of  the  nose  above  the  aperture;  the  skin 
here  must  be  preserved  intact  for  use  later. 

Second  Stage.  Preparation  of  Flap  from  Forehead. — This  procedure  is 
identical  with  that  of  Schimmelbusch  except  that  Lexer  at  once  covers  the  bone 
in  the  flap  with  skin  by  flolding  the  flap  on  itself  (Figs.  270  and  271).  The 
wound  in  the  forehead  should  be  covered  by  Thiersch  or  Wolf  skin  grafts. 

Third  Stage. — (Three  or  four  weeks  later.)  Step  i. — Formation  of  pedicle 
for  the  forehead  flap. 

The  flap  on  the  forehead  formed  in  Stage  2  was  provided  with  a  broad 
pedicle  whose  base  was  on  a  level  with  the  eyebrows  (Fig.  270).  Lexer,  in 
several  sittings,  gradually  step  by  step  continues  the  cuts  which  outline  the 
forehead  flap  downwards  until  they  reach  on  one  side  the  inner  angle  of  the 
eye,  on  the  other  side  the  nasal  opening  (Fig.  272).  From  the  latter  incision 
he  separates  the  skin  of  the  root  of  the  nose  from  the  bone  until  the  middle 
line  is  reached  (Fig.  273)  and  it  becomes  possible  to  twist  the  pedicle  and  bring 
the  flap  into  position  without  tension. 


i68 


OPERATIONS    UPON    THE   NOSE. 


Step  2. — ^From  the  under  surface  of  the  forehead  flap  reflect  a  narrow  flap 
of  skin  to  form  the  septum  or  philtrum  of  the  new  nose  (Fig.  273)  and 
through  the  wound  thus  made  divide  the  bone  in  the  flap  longitudinally  so  as 
to  fold  the  bone  on  itself  as  in  Schimmelbusch's  operation. 


Fig.   269. — {Lexer.) 


Fig.  270. — {Lexer.) 

y  y  /•  /•. 


Fig.   271 — {Lexer.) 


Fig.    273. — {Lexer.) 
{Archiv  filr  Klin.  Chir.) 


Step  3. — ^Freshen  the  edges  of  the  nasal  aperture  and  suture  the  forehead 
flap  in  proper  position  as  in  Schimmelbusch's  method. 

Fourth  Stage. — After  several  weeks  divide  the  pedicle  using  its  remnants  to 
help  to  repair  the  defect  between  the  eyebrows.     It  is  better  to  delay  this 


RHINOPLASTY. 


169 


step  as  long  as  possible,  as  when  the  pedicle  is  divided  the  transplanted  bone 
may  atrophy  especially  in  syphilitics. 

The  result  of  the  operation  so  far  is  to  provide  the  patient  with  a  hideous 
excrescence  which  an  Ananias  or  an  enthusiast  might  call  a  nose.  Lexer  next 
proceeds  to  fashion  a  nose  from  the  excrescence. 

Fifth  Stage. — This  stage  is  begun  a  few  weeks  after  the  pedicle  has  been 
divided. 

I.  Formation  of  a  Depression  Between  the  Forehead  and  the  Nose.— -hi 
the  level  of  the  eyes  divide  the  scars,  in  front  of  the  angle  of  the  eye,  down 
to  the  bone  excising  any  disfiguring  scar  tissue.  The  cuts  made  for  this  pur- 
pose are  about  2  cm.  long.  From  these  cuts  on  each  side  separate  the  soft 
parts  from  the  bone  and  cut  away  all  oedematous  and  thickened  connective 
tissue  (Fig.  274,  b). 


Fig.    274. — [Lexer.) 


The  subcutaneous  excision  of  scar  tissue  leaves  a  superfluous  amount  of 
skin  and  hence  it  is  necessary  to  convert  the  lateral  linear  incisions  into  ellipses 
(Fig.  274,  b)  by  excising  a  little  skin  from  their  anterior  margins  before  closing 
them   vnth   sutures. 

2.  Formation  of  the  Point  of  the  Nose. — The  tissues  about  the  point  of  the 
nose  have  sunk  down  and  are  too  voluminous. 

On  the  under  surface  of  the  new  nose  make  a  semilunar  incision  which 
reaches  near  the  base  of  the  septum  nasi  already  constructed  (Fig.  275,  a). 
Through  this  incision  pass  an  elevator  and  raise  the  skin  of  the  tip  of  the 
nose  from  the  underlying  bone  (obtained  from  the  forehead) .  Obtain  a  fresh 
piece  of  bone  from  a  rib  or  tibia  of  the  same  patient  or  from  some  other  person 
who  has  required  an  amputation  or  resection.  Model  this  fragment  of  bone 
into  an  oval  with  a  shallow  groove  on  its  «o«-periosteal  side  and  with  some- 


170  OPERATIONS   UPON   THE   NOSE. 

what  of  a  convexity  on  its  periosteal  side.  Push  this  fragment  into  the  bed 
prepared  for  it  at  the  tip  of  the  nose,  periosteum  towards  the  surface,  in  such 
a  manner  that  it  lies,  subcutaneously,  on  the  bony  support  of  the  new  nose 
and  forms  a  rounded  tip  to  it.  The  pushing  in  of  the  fragment  of  bone 
makes  the  semilunar  incision  gape  somewhat  but  this  open  wound  will  heal 
by  granulation  satisfactorily  (Figs.  274,  c,  and  275,  b  and  c).  For  a  few  days 
it  may  be  necessary  to  leave  a  pin  in  situ  perforating  the  fragment  of  bone 
and  keeping  it  from  being  misplaced. 

3.  Formation  of  the  Alee  of  the  Nose. — The  curved  incision  used  for  the 
implantation  of  bone  to  form  the  point  of  the  nose  in  healing  contracts  and 
leaves  a  small  notch  which  when  seen  from  the  side  acts  as  an  anterior  margin 
to  the  lower  edge  of  the  alae.  To  make  this  notching  more  distinct  and  to 
make  the  clumsy  lower  edge  of  the  new  nose  thinner,  subcutaneously  excise 
through  the  curved  incision,  the  soft  tissues  on  the  inner  side  of  the  bony 


a  be 

Fig.  275. — {Lexer.) 

support  of  the  nose  and  with  fine  forceps  cut  out  a  notch  in  the  bone  on  each 
side  so  as  to  widen  the  nostrils  (Figs.  274,  c,  and  275,  b).  Last  of  all  fashion 
the  outer  side  of  the  alae  by  excising  a  small  amount  of  skin  as  in  Fig.  274,  d, 
but  in  suturing  this  wound  stitch  its  posterior  cutaneous  edge  not  to  its  anterior 
cutaneous  edge  but  to  the  subcutaneous  tissue  in  front  of  the  wound,  thus  ob- 
taining a  more  or  less  sightly  indentation. 

III.  The  destruction  of  tissue  involves  only  the  osseous  and  cartilaginous 
framework  of  the  nose,  the  surface  being  left  intact. 

Finney's  Operation. — Step  1. — Cut  away  the  nail  and  its  matrix  from  the 
ring  finger  of  the  left  hand.  Remove  the  skin  from  the  back  of  the  finger 
up  to  its  middle  joint.  Denude  the  tip  of  the  finger  completely,  leaving  the 
tip  of  the  bone  bare.     Stop  bleeding. 

Step  2. — Introduce  a  tenotome  into  the  nose  and  divide  all  the  cicatricial 
connections  between  the  retracted  tip  of  the  nose  and  the  frontal  and  supe- 
rior maxillary  bones.  Pull  the  soft  parts  of  the  nose  forwards  into  the  best 
possible  position.  Do  not  cut  the  skin.  Vivify  the  inner  surface  of  the 
dorsum  of  the  nose  in  the  middle  line. 

Step  3. — Introduce  the  prepared  ring  finger  into  the  nose  in  such  fashion 
that  the  tip  of  the  exposed  phalanx  lies  in  contact  with  the  nasal  process  of 
the  frontal  bone  and  the  raw  surface  of  the  dorsum  of  the  finger  is  in  con- 


RHINOPLASTY. 


171 


tact  with  the  raw  median  surface  of  the  inside  of  the  dorsum  of  the  nose. 
Hold  the  finger  in  position  with  stitches  uniting  the  edges  of  the  finger  wound 
to  the  free  border  of  the  tip  of  the  nose. 

Step  2. — Hold  the  hand  in  position  by  means  of  adhesive  strips  and  plaster 
of  Paris  for  two  weeks. 

Step  5. — (Two  weeks  later).  Disarticulate  the  finger  at  the  metacarpo- 
phalangeal joint.     Apply  dressings. 

Step  6. — (One  week  later  than  Step  5).  Split  the  tissues  in  the  middle 
line  over  the  nasal  spine  of  the  superior  maxilla.  Flex  the  finger  at  the  proxi- 
mal phalangeal  joint.  Insert  the  free  end  of  the  proximal  phalanx  into  the 
wound  made  over  the  nasal  spine  of  the  superior  maxilla  and  fix  it  there 
with  sutures. 


Fig.  276. 


"^ffimn^ 


Fig.  278. 


The  proximal  phalanx  forms  the  column  of  the  nose;  the  two  other  pha- 
langes form  the  dorsal  support.  Later  some  minor  operations  will  be  neces- 
sary to  narrow  the  new  column  of  the  nose  and  to  improve  appearances. 

Kdnig's  Operation. — This  operation  was  originally  devised  for  the 
correction  of  saddle-nose,  but  it  is  also  of  great  value  in  the  treatment  of  cases 
where  the  soft  parts  are  absent  as  well  as  the  hard.  The  operation  as  here 
described  is  that  done  for  saddle-nose;  the  modifications  required  when  the 
soft  parts  are  absent  are  so  self-evident  that  they  vidll  not  be  mentioned. 

Step  I. — Make  a  transverse  incision  across  the  seat  of  the  saddle  (A,  B, 
Fig.  276).     Pull  the  tip  of  the  nose  down  into  correct  position. 

Step  2. — From  the  forehead  turn  down  the  vertical  flap  D  (Figs.  277  and 
27S)  and  suture  its  free  extremity  to  the  point  C  at  the  tip  of  the  nose.  This 
flap  is  1/2  inch  wide  and  is  made  by  cutting  through  the  soft  parts  Avith  a 
knife,  introducing  a  chisel  through  the  upper  part  of  the  wound,  and  thus 


172  OPERATIONS   UPON   THE   NOSE. 

elevating  a  long  narrow  strip  consisting  of  skin,  periosteum,  and  the  outer 
table  of  the  skull.     The  bone  in  the  flap  gives  firmness  to  the  new  nose. 

Step  3. — After  the  Indian  fashion,  reflect,  from  the  forehead,  a  skin-flap, 
E,  F,  G  (Fig.  277),  and  turn  it  down  so  as  to  cover  the  nasal  defect  A,  B,  C 
(Figs.    277   and   279),   as  well   as  flap   D. 

The  results  obtained  from  this  operation  or  some  of  its  modifications 
have  been  very  satisfactory. 

Author's  Method. — This  is  suitable  in  cases  where  the  nasal  bones  are 
intact  but  all  the  cartilaginous  septum  has  been  destroyed. 

Step  I. — Without  injuring  the  perichondrium  excise  by  sharp  dissection 
thin  strips  of  cartilage  from  the  eighth  rib.  The  strips  should  be  about  i  1/2 
inches  long,  1/4  inch  wide  and  1/8  inch  thick.  Preserve  these  in  warm  salt 
solution.     Close  the  wound. 

Step  2. — With  a  tenotome  introduced  either  through  the  skin  or,  as  in  Fin- 
ney's operation,  through  the  nose,  divide  the  cicatricial  connections  of  the 
nose  to  the  pyriform  aperture.  Pull  the  nose  forwards  into  as  good  position 
as  possible. 

Step  3. — Introduce  a  tenotome  through  the  skin  in  the  middle  line  of  the 
nose  just  below  the  osseous  nasal  bridge.  From  the  puncture  make  a  tunnel 
between  the  skin  and  the  mucosa  on  each  side  down  to  the  junction  of  the 
nasal  alae  and  the  upper  lip,  where  the  skin  is  again  perforated.  With  an 
eyed  probe  or  a  forceps  pull  a  thread  and  by  means  of  the  thread  pull  a 
strip  of  cartilage  through  each  tunnel.  Do  not  permit  the  ends  of  the  cartilage 
to  protrude  through  the  skin  punctures.  The  strips  of  cartilage  act  as  splints 
or  braces  for  the  nose.  Of  course  it  is  easy  to  introduce  a  strip  of  cartilage  at 
any  place  where  it  will  do  most  good. 

Israel's  Operation. — This  is  merely  a  modification  of  Konig's  method, 
but  gives  better  cosmetic  results.  The  flap  D  (Fig.  278)  is  made  narrow, 
being  only  about  1/8  inch  wide,  and  when  turned  down  and  its  free  end 
sutured  in  place,  exactly  as  in  Konig's  operation,  it  is  left  uncovered  by  any 
other  flap.  After  a  short  time  the  raw  surface  of  the  flap  becomes  covered 
by  granulation  tissue  and  the  epidermis  spreads  over  it.  The  local  condition 
is  now  the  following. 

The  tip  of  the  nose  is  in  normal  position.  The  skin  and  bone  flap  D 
(Fig.  278)  bridges  over  the  defect  created  by  the  incision  A,  B  (Fig.  276), 
and  also  the  undivided  skin  at  the  root  of  the  nose.  Whenever  flap  D  has 
become  well  healed,  draw  it  slightly  to  one  side;  make  a  vertical  median  in- 
cision through  the  skin  at  the  root  of  the  nose  above  the  defect.  Elevate 
this  skin  on  each  side  of  the  median  incision,  bring  the  edges  up,  and  suture 
them  to  the  vivified  edges  of  the  new  nasal  bridge  (flap  D,  Fig.  278). 

Von  Mangold's  Operation. — Step  i. — Make  a  small  transverse  incision 
across  the  middle  line  through  the  skin  at  the  glabella.  With  a  Kocher  sound 
or  blunt  dissector  burrow  a  tunnel  under  the  skin,  in  the  middle  line  down  to 
the  point  of  the  nose. 


RHINOPLASTY.  1 73 

Step  2. — Expose  by  incision  the  seventh  or  eighth  costal  cartilage.  Excise 
a  plate  of  cartilage,  with  its  perichondrium,  about  i  3/4  inches  long,  3/8 
inch  wide,  and  1/8  inch  thick. 

Step  3. — Push  the  excised  plate  of  cartilage  into  the  subcutaneous  tunnel 
prepared  on  the  nose.  The  side  of  the  graft  which  has  no  perichondrium 
ought  to  be  directed  towards  the  skin.     Close  the  little  wound  with  sutures. 

Step  4. — Make  a  small  incision  through  the  skin  in  the  grooves  to  the  out- 
side of  each  ala  of  the  nose.  Through  these  incisions  implant  a  thin  strip 
of  costal  cartilage  in  each  ala. 

Von  Mangold  was  able  to  form  good  nares,  to  correct  saddle  shape  and  to 
obtain  a  rectilinear  nose,  but  it  was  necessary  to  lengthen  and  improve  the 
shape  of  the  organ  at  a  second  operation  after  an  interval  of  five  months. 

Second  Operation. — Through  an  inverted  V-shaped  incision  (apex  of  V 
in  middle  line  at  root  of  nose,  legs  of  V  coming  down  on  each  side  of  the  nose) 
detach  the  soft  structures  of  the  nose  and  with  them  the  cartilaginous  graft, 
from  the  subjacent  structures.  Carefully  apply  the  upper  end  of  the  graft 
of  cartilage  into  the  angle  between  the  glabella  and  the  root  of  the  nose. 
Suture  the  wounds. 


CHAPTER  XVIII. 
TORTICOLLIS.     WRY-NECK.     CAPUT  OBSTIPUM. 

There  are  several  methods  of  operating  on  torticollis. 

(a)  Subcutaneous  tenotomy  of  the  sternal  and  clavicular  portions  of  the 
sternomastoid.  This  operation  is  rarely  performed,  as  its  only  advantage 
lies  in  the  absence  of  scar,  while  its  disadvantages  are  danger  and  incom- 
pleteness. 

(b)  Open  section  of  the  same  structures,  plus  division  of  all  bands  of 
fibrous  tissue  which  obstruct  reduction  of  the  deformity. 

(r)   Excision  of  the  degenerated  sternomastoid  (Mikulicz). 
When  the  torticollis  is  of  the  spasmodic  variety,"  the  following  methods 
have  bee  advised: 

(d)  Division  or  excision  of  the  spinal  accessory  nerve. 

(e)  Multiple  myotomy  (Kocher). 

Open  Tenotomy  of  Sternomastoid. — The  favorite  site  for  dividing 
the  muscle  is  1/2  to  3/4  inch  above  the  clavicle.  The  skin  incision  may  be 
vertical,  oblique,  or  transverse;  probably  the  oblique  is  best.  Beginning 
at  the  outer  edge  of  the  sternal  attachment  of  the  sternomastoid,  make  an 
incision  i  to  11/2  inches  in  length,  passing  upwards  and  outwards  to  the 
middle  of  the  anterior  margin  of  the  clavicular  portion  of  the  muscle.  Re- 
traction of  the  wound  exposes  both  portions,  which  are  easily  isolated  and 
divided  without  danger  to  other  structures.  Rotate  the  head  firmly  towards 
the  sound  side,  keeping  the  shoulder  of  the  affected  side  steady.  This  ma- 
noeuvre puts  all  other  contracted  structures  on  the  stretch.  Divide  all  such, 
even  down  to  beside  the  carotid  packet  of  vessels.  Attend  carefully  to  hemo- 
stasis.  Suture.  Dress.  Lorenz  advises  forcible  overcorrection  before  the 
patient  comes  out  of  the  anaesthesia.  The  corrected  or  overcorrectcd  posi- 
tion must  be  retained  either  by  an  extension  apparatus  or  by  means  of  a  proper 
collar.  After  healing  has  taken  place,  massage,  exercise,  and,  for  a  time, 
the  use  of  some  orthopedic  apparatus,  such  as  Sayre's  are  requisite. 

Myomectomy. — Mikulicz's  Operation. — In  severe  cases  of  torticollis 
Mikulicz  advises  excision  of  the  lower  two-thirds  of  the  sternomastoid,  the 
upper  one-third  being  preserved  so  as  to  avoid  injury  to  the  spinal  accessory 
nerve. 

Expose  and  divide  the  sternal  and  clavicular  portions  of  the  muscle  as  in 
open  tenotomy.  Seize  the  divided  ends  in  forceps  and  pull  the  muscle  down- 
wards and  through  the  skin-wound;  as  this  is  done,  separate  it  from  its  sur- 
roundings by  blunt  and  sharp  dissection.     Avoid  injuring  the  external  jugular 

174 


WRY   NECK.  175 

vein.  When  two-thirds  of  the  muscle  is  isolated,  divide  and  remove  it.  At- 
tend to  hemostasis.  Divide  all  cicatricial  bands  which  can  be  felt.  Close 
the  wound.  Apply  dressings  and  pressure  enough  to  obviate  dead  spaces. 
No  subsequent  orthopedic  treatment  is  required. 

Bruns  in  doing  this  operation  removes  only  one- third  of  the  muscle.  The 
chief  disadvantage  of  the  operation  is  cosmetic,  viz.,  the  loss  of  the  shapeli- 
ness of  the  neck.     It  should  be  reserved  for  severe  or  recurrent  cases. 

Division  of  the  Spinal  Accessory  Nerve. — The  spinal  accessory  nerve 
escapes  from  the  skull  through  the  jugular  foramen.  It  runs  obliquely  down- 
wards and  backwards  between  the  internal  jugular  vein  and  the  digastric  mus- 
cle, entering  the  sternomastoid  muscle  at  a  point  about  two  inches  below 
the  mastoid  process.  The  nerve  pierces  the  muscle  obliquely  and  proceeds 
across  the  posterior  triangle  of  the  neck  to  supply  the  trapezius. 

The  Operation. — Make  an  incision  2  1/2  to  3  inches  in  length  from  the 
mastoid  process  downwards  along  the  anterior  border  of  the  sternomastoid. 
Expose  the  anterior  border  of  the  muscle  and  divide  the  cervical  fascia.  Re- 
tract the  muscle  backwards.  With  the  finger  recognize  the  transverse  process 
of  the  altas,  which  is  covered  by  the  digastric  muscle.  The  nerve,  after  pass- 
ing between  the  bony  process  and  the  muscle,  emerges  at  the  lower  edge  of 
the  latter  and  passes  to  the  sternomastoid.  Expose  the  nerve  and  either 
divide  it  or  excise  about  1/2  inch  of  it.  Close  the  wound  with  sutures.  Dress. 
The  results  of  the  operation  are  usually  good;  the  danger  is  practically »//. 

Nerve  Section  for  Spasmodic  Torticollis. — Division  of  the  posterior 
primary  divisions  of  the  cervical  nerves  was  first  carried  out  by  Gardner  of 
Adelaide  and  Keen  of  Philadelphia  in  1888.  The  operation  is  only  suitable 
for  very  severe  cases  in  which  the  disease  has  rendered  life  a  burden.  The 
object  of  the  operation  is  to  paralyze  all  the  muscles  involved — e.  g.,  when  the 
spasm  turns  the  head  to  the  right  and  extends  it  one  should  paralyze  the  left 
sternomastoid  and  trapezius  and  the  right  splenius  capitis,  trachelomastoid, 
superior  and  inferior  oblique,  rectus  capitis,  posticus  major,  complexus  and 
trapezius. 

Robert  Kennedy  ("Brit.  Med.  Joum.,"  Oct.  3,  1908)  has  endeavored  to 
simplify  the  exposure  of  the  nerves,  no  easy  matter  at  the  best. 

Step  I. — Make  a  vertical  skin  incision  from  1/2  inch  above  the  superior 
curved  line  downwards  for  3  to  3  1/2  inches  midway  between  the  external 
ear  and  the  external  occipital  protuberance. 

Step  2. — Define  the  posterior  edge  of  the  sternomastoid  and  deepen  the 
incision  behind  the  sternomastoid  until  the  oblique  fibres  of  the  splenius 
capitis  are  exposed.  Do  not  injure  the  spinal  accessory  nerve  which  may 
lie  near  the  lower  angle  of  the  wound. 

Step  3. — Define  the  upper  border  of  the  splenius  capitis  and  divide  that 
muscle  in  the  line  of  the  original  incision.  Divide  the  subjacent  connective 
tissue  exposing,  above,  the  complexus  whose  fibres  run  longitudinally,  and 
below,  the  trachelomastoid  whose  fibres  run  obliquely. 


176  TORTICOLLIS.      WRY-NECK.      CAPUT   OBSTIPUM. 

Define  the  outer  edge  of  the  complexus  and  the  upper  edge  of  the  trachelo- 
mastoid. 

The  upper  part  of  the  wound  is  crossed  by  the  occipital  vessels.  Deep 
down  in  a  triangle  formed  by  the  occipital  vessels  and  the  two  muscles  lies 
the  superior  oblique  muscle. 

Step  4. — Follow  the  outer  border  of  the  complexus  to  its  highest  slip  of 
origin  (third  cervical  articular  process).  Detach  this  slip  from  the  bone. 
Repeat  this  with  the  slip  originating  from  the  fourth  articular  process.  Re- 
tract the  trachelomastoid  outwards.  Fold  the  complexus  inwards  and  so 
expose  several  nerves  entering  its  deep  surface.  "The  largest  is  the  great 
occipital  or  internal  branch  of  the  posterior  primary  division  of  the  second 
cervical,  and  this  pierces  the  complexus  about  the  level  of  the  lower  edge  of  the 
lobe  of  the  ear.  Above  the  point  at  which  the  great  occipital  enters  the  com- 
plexus a  slender  branch  can  be  seen  entering  the  muscle  and  it  can  be  traced 
back  to  the  posterior  primary  division  of  the  first  cervical  nerve.  The  latter, 
however,  is  best  found  by  tracing  out  the  slender  branch  of  communication 
with  the  second  posterior  primary  division  which  as  a  rule  is  present,  passing 
upwards  from  the  second  division  across  the  inferior  oblique.  It  is  very  diflfi- 
cult  to  deal  satisfactorily  with  the  suboccipital  nerve  unless  this  communi- 
cating branch  is  early  found  and  traced  upwards  at  once  to  the  first  division 
which  lies  between  the  vertebral  artery  and  the  arch  of  the  atlas,  and,  of  course, 
the  operation  is  only  imperfectly  performed  unless  the  first  division  is  ade- 
quately dealt  with.  A  short  communicating  branch  leads  from  the  second  divi- 
sion down  to  the  third  division  and  is  a  safe  way  of  reaching  the  latter.  The 
fourth  and  fifth  divisions  can  be  easily  found  passing  downwards  and  back- 
wards close  to  the  vertebrae.  The  nerves,  from  the  second  downwards,  should 
be  isolated  to  the  point  of  separation  into  anterior  and  posterior  primary 
divisions,  but  not  further,  and  undue  traction  can  quite  easily  pull  the  anterior 
primary  division  backwards  and  expose  it  to  the  danger  of  being  damaged. 
The  first  nerve  is  sectioned  just  proximal  to  its  branches,  and  the  others  near 
their  point  of  separation  from  the  anterior  primary  division.  In  the  great 
majority  of  cases  the  nerves  once  sectioned  are  excised  from  the  point  of  sec- 
tion as  far  distally  as  can  be  reached." 

Step  5. — The  nerves  having  been  exposed  excise  a  segment  of  each.  Do 
not  stretch  the  nerves  lest  rupture  of  the  roots  occur  and  paralyze  the  anterior 
primary  divisions.  Resection  of  the  nerves  means  total  and  permanent  pa- 
ralysis of  the  muscles  involved.  Kennedy  suggests  another  method  of  operation 
in  cases  where  the  spasm,  though  very  violent,  has  not  been  of  long  standing, 
and  which  refuses  to  yield  to  any  known  treatment  short  of  operation.  In 
such  acute  cases,  i.  e.,  where  the  affection  has  lasted  only  a  few  months  and 
there  seems  hope  of  cure,  Kennedy  gives  the  muscles  rest  by  dividing  and 
immediately  suturing  the  spinal  accessory  of  one  side  and  the  posterior  primary 
divisions  of  the  opposite  side.  "The  result  is  that  the  violent  spasm  is  im- 
mediately abolished,  the  affected  muscles  degenerate,  and  in  the  course  of 


WRY   NECK.  177 

some  weeks,  after  the  nerves  have  regenerated,  as  indicated  by  the  gradually 
returning  sensation,  the  muscles  begin  to  get  built  up  again  and  shortly  begin 
to  resume  their  functions." 

Multiple  Myotomy. — Kocher's  Operation. — Two  incisions  are  necessary. 

1.  Make  an  incision  i  1/4  to  i  1/2  inches  in  length  along  the  anterior 
border  of  the  sternomastoid,  commencing  opposite  the  angle  of  the  jaw  and 
passing  upwards.  Divide  the  platysma  and  if  possible  save  the  external 
jugular  vein.  Open  the  sheath  of  the  sternomastoid  along  its  anterior  border. 
Introduce  a  blunt  dissector  under  the  muscle  and  divide  it  layer  by  layer. 
Attend  to  hemostasis.  Close  the  wound  with  sutures.  If  desired,  the  spinal 
accessory  nerve  may  be  stretched  or  divided  during  this  procedure. 

2.  The  patient  is  turned  on  to  his  sound  side.  Beginning  at  the  mastoid, 
make  a  transverse  incision  backwards.  Through  this  divide  the  trapezius 
transversely  and  incise  the  splenius  capitis  and  complexus  muscles.  Avoid 
injuring  the  great  occipital  nerve,  which  here  traverses  the  complexus  and 
trepezius.  The  inferior  oblique  muscle  arises  from  the  spinous  process  of 
the  axis  and  is  inserted  into  the  transverse  process  of  the  atlas.  Look  for  this 
muscle  in  the  space  between  the  atlas  and  axis  and  divide  it.  Attend  to 
hemostasis.     Close  the  wound. 

Monod  and  Vanverts  write  as  follows:  "Section  should  be  made  of  the 
muscles  which  participate  in  the  spasm.  It  is  necessary,  by  analysis,  to  deter- 
mine prior  to  operation  the  muscles  involved.  One  may  be  compelled  to  practise, 
according  to  the  case,  the  following  operations:  division  of  sternomastoid  and  of 
the  muscles  of  the  nape  of  the  neck  on  the  opposite  side  (typical  rotary  tic); 
division  of  the  sternomastoid  and  of  the  muscles  of  the  nape  of  the  neck  on  the 
same  side  (rotary  tic  with  predominance  of  lateral  deviation);  division  of  sterno- 
mastoid and  bilateral  division  of  the  muscles  of  the  nape  of  the  neck  (rotary  tic 
with  much  posterior  extension)." 

Remarks. — In  some  cases  of  torticollis  no  operation  seems  to  be  effectual; 
such  are  usually  due  to  affections  of  the  posterior  nerve  and  muscle  groups. 
Extirpation  of  the  nerves  involved  has  been  advised,  but  this  is  a  very  compli- 
cated, and  for  most  surgeons  inadvisable  operation,  and  is  not  a  glittering 
success. 

In  other  cases  any  operation  involving  tenotomy  is  successful.  When 
the  muscle  is  greatly  degenerated  and  adherent,  Mikulicz's  procedure  is  the 
best.  In  spasmodic  varieties  of  torticollis  section  of  the  spinal  accessory  nerve 
is  the  operation  of  choice. 


CHAPTER  XIX. 
EXCISION  OF  CERVICAL  TUMORS. 

The  various  operations  for  the  removal  of  cervical  tumors,  if  at  all  exten- 
sive, should  never  be  undertaken  by  a  tyro  in  surgery.  These  operations 
are  very  dangerous  in  the  hands  of  one  who  is  not  possessed  of  a  good  working 
knowledge  of  anatomy,  especially  of  the  anatomy  of  the  living,  and  of  wide 
surgical  experience. 

A  good  type  of  the  operations  under  discussion  is  the  removal  of  tubercu- 
lous glands.  Ideally,  when  the  disease  is  extensive,  one  should  endeavor 
to  remove  all  the  cervical  glands,  and  their  lymphatic  connections  in  one 
piece.  This  is,  of  course,  impossible;  but  it  is  a  good  plan  for  the  surgeon 
to  try  to  approximate  the  ideal,  even  although  he  knows  that  his  endeavors  to 
do  so  will  fall  far  short. 

What  are  the  dangers  of  the  operation? 

1.  Hemorrhage. — If  care  is  taken,  bleeding  need  cause  little  anxiety. 
The  precautions  taken  to  avoid  air  embolism  will  certainly  have  the  effect 
of  preventing  much  hemorrhage. 

2.  Air  Embolism. — During  inspiration  the  blood  in  the  cervical  veins 
is  under  negative  pressure.  If  under  these  circumstances  the  vein  is  wounded, 
air  is  liable  to  be  sucked  into  it  and  thus  into  the  heart — a  very  fatal  accident. 
Careful  attendance  to  the  principles  of  technic  for  cervical  operations  will 
obviate  most  of  the  danger. 

(a)  The  wound  through  the  skin  and  fascia  should  be  large  enough  to 
give  free  access  to  every  part  to  be  operated  upon. 

(b)  The  wound  should  be  kept  moist,  and  if  the  slightest  "hissing"  sound 
be  heard  in  the  wound,  the  finger  should  press  the  tissue  at  a  point  nearer  the 
heart  than  where  the  wounded  vein  is.  The  "hissing"  signifies  entrance  of 
air.  The  digital  pressure  is  meant  to  hinder  the  passage  of  the  air  towards 
the  heart.  At  the  same  time  as  the  finger  pressure  is  applied,  a  spongeful  of 
water  must  he  squeezed  into  the  wound.  This  effectually  prevents  more  air 
getting  in.  The  wound  in  the  vessel  must  be  caught  by  pressure  forceps.  J. 
B.  Murphy  places  a  small  pack  of  gauze,  with  a  thread  attached  to  it  to  keep 
it  from  being  lost,  under  the  sternal  attachment  of  the  sternomastoid  muscle. 
The  pressure  of  the  pack  keeps  the  cervical  veins  full,  prevents  the  danger  of 
negative  pressure,  and  makes  the  veins  very  visible.  This  expedient  is  of  great 
value;  the  trifling  increase  in  hemorrhage  is  of  no  importance.  When  "his- 
sing" in  the  wound  occurs  and  makes  one  suspect  air  embolism,  remember 
that  it  may  be  due  to  the  pleura  being  accidentally  opened.  The  pleura 
extends  an  inch  or  more  above  the  first  rib. 

178 


CERVICAL   OPERATIONS.  1 79 

{c)  No  more  cutting  should  be  done  than  is  absolutely  necessary.  Blunt 
dissection  is  most  meritorious. 

(d)  Never  cut  in  the  dark  or  without  full  knowledge  of  the  safety  of  what 
is  being  divided. 

(e)  Bleeding  points  are  at  once  caught  by  pressure  forceps.  If  it  is  sus- 
pected that  forcipressure  kept  up  for  a  few  minutes  will  be  insufficient  to  stop 
the  bleeding,  the  vessel  should  be  secured  by  a  fine  ligature. 

(J)  In  removing  the  glands  no  forcible  tearing  should  be  perpetrated. 
Veins  are  often  very  friable. 

(g)  Structures  about  to  be  cut  ought  not  to  be  on  tension.  Tension 
empties  veins    and  makes  them  look  like  bands  of  fibrous  tissue. 

(h)  When  in  the  slightest  doubt  as  to  the  contents  of  a  strand  of  tissue 
which  must  be  severed,  apply  two  forceps  or  two  ligatures  and  cut  between. 

When,  in  spite  of  all  precautions,  air  has  been  sucked  into  a  vein,  fill  the 
cervical  wound  loosely  with  wet  gauze;  do  not  apply  forceps  to  the  vein;  during 
the  succeeding  expirations  forcibly  compress  the  chest;  do  not  lower  the  head 
and  shoulders  of  the  patient. 

3.  When  operating  down  low  in  the  neck  on  the  left  side,  avoid  injuring 
the  thoracic  duct.  Such  injury  is  not  uncommon.  If  noticed  at  the  time, 
one  sees  a  little  clear  fluid  escaping.  Compression  sutures  in  the  vicinity  of 
the  injured  duct  plus  gauze  packing  usually  leads  to  recovery,  but  fluid  escapes, 
in  spite  of  treatment,  for  about  two  weeks,  and  there  is  great  emaciation.  The 
injury  generally  heals  in  about  three  weeks  or  less.  P.  Lecene  thoroughly 
discusses  this  accident  ("Revue  de   Chir.,"   Dec,    1904). 

4.  Injury  to  Important  Nerves. — The  danger  of  injuring  important 
nerves  in  the  neck  is  by  no  means  great.  The  vagus  is  well  protected,  lying 
in  the  carotid  sheath.  If  care  be  taken,  the  spinal  accessory  nerve  can  usually 
be  recognized  and  often  preserved;  its  preservation  is  of  much  greater  impor- 
tance in  the  young  than  in  the  mature.  Injury  to  the  phrenic  and  the  recur- 
rent laryngeal  nerves  is  extremely  rare.  Injury  to  the  cervical  sympathetic 
system  seems  to  produce  no  ill  results. 

The  Operation. — In  slight  cases  where  the  glands  are  neither  numerous 
nor  adherent  the  operation  is  extremely  simple.  An  incision  is  made  over 
the  swelling,  and  through  this  the  tumors  are  easily  shelled  out.  The  method 
of  operating  about  to  be  described  is  for  extensive  and  complicated  disease. 

The  patient  lies  on  his  back  with  the  shoulders  supported  and  the  head 
turned  towards  the  side.  The  scalp  should  be  covered  by  a  well-fitted  gauze 
or  rubber  cap,  to  keep  the  hair  out  of  the  way.  An  oblique  incision  is  made 
along  the  sternomastoid  muscle  from  the  mastoid  process  to  near  the  sterno- 
clavicular articulation.  The  external  jugular  vein  is  exposed  and  divided  be- 
tween two  ligatures.  The  skin  anterior  and  posterior  to  the  incision  is  dissected 
from  the  subjacent  tissues  and  retracted.  If  necessary,  a  second  cut  may  be 
made  parallel  to  and  near  the  clavicle,  from  the  lower  end  of  the  oblique  incision 
outwards.     Another  incision,  and  one  which  leaves  little  noticeable  scar,  follows 


i8o 


EXCISION    OF    CERVICAL    TUMORS. 


the  margin  of  the  vertical  hair  line  of  the  back  of  the  neck;  to  this  cut  is  joined 
one  following  the  clavicle  forwards  (Fig.  279).  Expose  the  sternomastoid 
and  free  it  from  its  surroundings  throughout  its  whole  length.  Notice  the  point 
of  emergence  of  the  superficial  cervical  nerves  at  the  posterior  edge  of  the 
muscle;  the  nerves  are  not  small,  and  here  the  muscle  is  more  firmly  attached 
to  its  surroundings  than  elsewhere,  hence  this  point  constitutes  an  anatomic 
landmark  (Fig.  280).  One-half  inch  above  this  landmark  the  spinal  accessory 
nerve  emerges  from  the  sternomastoid  muscle  and  is  easily  found.  The  nerve 
enters  the  muscle  about  two  inches  below  the  tip  of  the  mastoid  process,  after 
passing  over  the  prominent  transverse  process  of  the  atlas.  In  cases  of  tubercu- 
losis it  is  commonly  easy  to  trace  the  nerve  in  its  course  to  the  trapezius  and 
to  separate  it  from  the  diseased  structures.  In  the  young  it  is  important  to 
preserve  the  nerve,  because  Fenger  has  shown  that  its  division  leads  to  drooping 
of  the  shoulder  and  to  scoliosis. 


Fig.  279. 


Fig.  280. 
Superficial  cervical  nerves. 


The  packet  of  fascia  which  contains  the  carotid  artery,  internal  jugular 
vein,  and  the  vagus  must  now  be  exposed.  Once  exposed,  the  protection  of 
these  extremely  important  structures  becomes  more  or  less  easy.  Up  to  this 
time  no  attempt  has  been  made  to  remove  diseased  tissues.  The  disease  is 
now  attacked.  Beginning  near  the  lower  end  of  the  wound  and  by  the  side  of 
the  carotid  packet,  the  removal  of  the  diseased  glands  with  the  gland-bearing 
fascia  is  generally  a  comparatively  easy  matter  and  can  be  carried  out  systemat- 
ically. If  the  important  anatomical  structures  are  not  exposed  and  protected 
at  an  early  stage  in  the  operation,  systematic,  thorough  removal  of  the  glands 
is  very  difficult  and  dangerous.  The  diseased  structures  having  been  removed 
and  all  hemorrhage  stopped,  carefully  suture  the  wound  in  the  cervical  fascia, 
preferably  with  catgut.  Suture  of  the  fascia  and  platysma  most  notably  re- 
moves tension  from  the  skin-wound.  If  the  fascia  is  not  well  united,  the  skin- 
wound  is  liable  to  stretch  and  give  rise  to  a  wide,  ugly  scar.  Provide  drainage 
at  the  lower  angle  of  the  wound.  Close  the  skin-wound  neatly,  using  in- 
tradermic  sutures  or  ordinary  sutures,  preferably  of  horse-hair.  Horse-hair 
sutures,  being  elastic,  leave  less  scar  than  sutures  of  any  other  material.     After 


TUBERCULOUS    GLANDS,    NECK.  l8l 

operations  on  the  neck,  very  extensiv*e  dressings  are  required  as  small  dressings 
are  difficult  to  keep  in  place. 

In  the  course  of  any  operation  for  the  removal  of  tuberculous  glands  some 
of  them  may  be  ruptured  and  from  them  there  escapes  caseous  material.  Such 
extravasated  matter  must  be  carefully  wiped  away,  and  it  is  good  practice 
to  scrape  the  remnants  of  the  caseated  material  from  the  ruptured  gland, 
subsequently  mopping  the  part  scraped  with  liquid  carbolic  acid,  followed 
by  the  application  of  alcohol  to  neutralize  the  carbolic.  When  glands  are  so 
firmly  united  to  the  great  vessels  of  the  neck  that  their  removal  is  very  risky, 
it  is  proper  to  remove  as  much  of  the  gland  as  possible  and  sterilize  the  re- 
mainder with  liquid  carbolic,  afterwards  neutralizing  with  alcohol. 

Subcutaneous  Removal  of  Tuberculous  Glands  in  the  Neck  and  Sub- 
maxillary Regions  (Dollinger's  Operation). — The  operator  sits  behind  the 
head  of  the  patient  and  wears  an  electric  headlight.  An  assistant  holds  the 
patient's  head  free  and  moves  it  to  suit  the  convenience  of  the  operator.  Be- 
ginning near  the  external  auditory  meatus,  make  an  incision,  2  1/2  to  3  inches 
in  length,  downwards  and  backwards,  parallel  to  and  about  1/3  inch  from  the 
margin  of  the  hair.  Through  this  incision  packets  of  glands  in  almost  all  the 
cervical  region  may  be  reached  and  removed  by  blunt  dissection,  the  surgeon 
undermining  the  skin  to  a  point  below  the  packet  to  be  removed  and  removing 
the  glands  from  below  upwards.  Nerves  and  vessels  must  be  pushed  aside. 
When  the  glands  are  seized  with  forceps,  they  often  tear  or  collapse,  especially 
if  they  are  caseated.  This  accident,  according  to  Dollinger,  does  no  harm, 
provided  the  debris  is  promptly  washed  away.  Cases  in  which  peri-adenitis 
has  caused  the  formation  of  many  firm  adhesions  are  unsuitable  for  this  opera- 
tion. After  removal  of  the  glands  the  whole  wound  must  be  reviewed,  cleaned, 
drained,  and  sutured.     The  hemorrhage  is  remarkably  slight. 

The  location  of  particular  groups  or  packets  of  glands  is  as  follows:  I. 
The  retroauricular  and  subauricular  glands  lie  next  to  the  incision  and  are 
easily  removed. 

II.  The  preauricular  glands  lie  on  the  parotid  beneath  the  masseteric 
fascia  which  they  penetrate  and  so  reach  the  subcutaneous  tissues.  To  reach 
them  pass  under  the  external  auditory  meatus.  The  facial  nerve  is  not  in 
danger. 

III.  The  glands  under  the  head  of  the  sternomastoid  lie  posterior  to  the 
accessory  nerve,  which  must  be  carefully  preserved. 

Glands  also  lie  in  front  of  and  beneath  the  nerve  and  must  be  removed 
with  great  care.  One  reaches  these  glands  from  the  wound  by  dissecting  under 
the  posterior  edge  of  the  sternomastoid. 

IV.  Glands  in  the  vicinity  of  the  lower  end  of  the  parotid  gland  and  of  the 
posterior  facial  vein  are  reached  by  burrowing  between  the  skin  and  the  sterno- 
mastoid. When  the  disease  is  of  long  standing,  the  posterior  facial  vein  is 
often  obliterated.  Preserve  the  external  jugular  vein  and  the  great  auricular 
nerves. 


l82  EXCISION   OF   CERVICAL   TUMORS. 

V.  Glands  about  the  submaxillary  Salivary  glands.  These  are  usually 
three  in  number  and  lie  between  the  salivary  gland  and  the  lower  jaw.  One 
next  burrows  between  the  skin  and  the  sternomastoid  to  the  group  of  glands 
anterior  to  the  muscle,  and  illuminating  the  wound  with  the  headlight,  opens 
their  fascial  covering  and  removes  them  bluntly. 

VI.  The  submental  glands,  two  in  number,  lie  between  the  anterior  bellies 
of  the  digastric.  These  are  best  removed  through  a  small  incision  directly 
over  them. 

VII.  Glands  in  the  lateral  triangle  of  the  neck  number  about  50.  The 
upper  ones  can  be  easily  reached  through  the  primary  incision.  The  lower 
ones  lying  in  loose  connective  tissue  are  easily  pushed  upwards  and  extirpated. 
Look  out  for  and  preserve  the  branch  of  the  spinal  accessory  going  to  the  trape- 
zius, the  cervical  and  the  brachial  plexus.  These  structures  are  separated 
from  the  glands  by  a  layer  of  cervical  fascia.  The  external  jugular  vein  is 
often  obliterated. 

VIII.  The  deep  cervical  glands  lie  along  the  great  vessels  under  the  sterno- 
mastoid, and  can  be  reached  by  undermining  the  muscle.  If  the  glands 
are  firmly  united  to  the  vessels,  pull  them  to  the  surface  with  a  sharp  hook  and 
carefully  dissect  them  free.  Remember  that  the  traction  empties  the  internal 
jugular  vein  and  makes  it  look  like  an  innocent  band  of  tissue. 

This  proceeding  seems  to  the  author  very  hazardous.  Bollinger's  opera- 
tion seems  to  be  excessively  difficult,  and  may  easily  be  very  incomplete,  but 
that  surgeon  has  performed  it  in  very  many  cases,  and  with  excellent  results. 
[Bollinger's  description  of  his  operation  appears  in  the  "Proceedings  of  the 
German  Surgical  Society,"  1903.] 

When  the  disease  for  which  operation  is  required  is  malignant,  almost 
everything  holds  good  which  has  been  said  regarding  the  excision  of  tuber- 
culous glands,  but  the  work  is  more  complicated  and  difficult.  That  malig- 
nant disease  should  be  excised  as  thoroughly  as  possible  is  as  true  in  the  neck 
as  elsewhere,  but  thoroughness  is  more  difficult  to  attain  in  this  region.  The 
incision  made  must  vary  according  to  circumstances.  It  may  be  obliquely 
vertical,  transverse,  or  a  horseshoe-shaped  flap  with  its  pedicle  upwards  or 
downwards  may  be  dissected  from  over  the  tumor.  When  the  growth  is  ex- 
posed, it  must  be  separated  from  its  surroundings.  In  doing  this  it  is  usually 
wise  to  attend  to  the  most  dangerous  part  first.  Thus,  when  feasible,  the 
surgeon  should  begin  the  enucleation  at  the  point  nearest  the  large  vessels, 
so  that  in  case  of  accident  or  difficulty  these  may  be  under  control.  If  the 
carotid  artery  or  the  internal  jugular  vein  passes  into  or  becomes  inseparably 
united  to  the  tumor,  it  is  well  to  know  the  trouble  early  in  the  operation  so  that 
one  may  intelligently  make  up  his  mind  as  to  the  propriety  of  braving  the 
dangers  of  a  completed  operation  or  the  advisability  of  closing  the  wound 
before   it   is   too   late   to   recede. 

The  carotid  artery  lies  deeper  then  the  vein  and  is  rarely  involved  in  the 
disease.     The  vein  is  often  infiltrated  or  surrounded  by  the  tumor  and  requires 


HYDROCELE,   NECK.  183 

ligation  or  removal,  which  is  not  particularly  dangerous.  Ligation  of  the 
common  carotid  has  a  mortality  of  about  26  per  cent,  (from  cerebral  softening 
principally).  In  operations  for  malignant  disease  Crile  applies  his  clamp 
(Fig.  281)  to  the  artery  and  thus  temporarily  controls  it.  Some  surgeons 
throw  a  soft  temporary  ligature  around  the  artery,  which  serves  the  same 
purpose  as  Crile's  clamp  but  does  not  do  so  in  quite  as  elegant  a  fashion. 
Temporary  control  of  the  carotid  is  of  great  value  in  operations  for  malignant 
neoplasms. 

If  it  seems  probable  that  the  tumor  may  be  dissected  free  from  the  vessels, 
it  is  often  proper  to  lay  a  ligature  loosely  in  position  around  the  internal  jugu- 


lar vein  (to  the  cardiac  side  of  the  growth)  so  that,  should  air  embolism  be 
seriously  threatened  during  the  later  stages  of  the  operation,  an  assistant  can 
quickly  tighten  the  thread  and  avert  danger. 

Note. — In  connection  with  severe  surgical  operations  on  the  neck  it  should  be  dis- 
tinctly understood  that  section  of  ihe  vagus  nerve  is  not  necessarily  fatal.  Giordano 
(quoted  in  "Annals  of  Surg.,"  June,  1894)  finds  that  after  maltreatment  of  the 
nerve  in  surgical  cases  the  mortality  is  not  higher  than  45  per  cent.,  while  in  resection 
it  is  75  per  cent.  Crile  ("Problems  Relative  to  Surgical  Operations,"  1901)  has 
made  numerous  experiments  on  the  vagus  and  reports  a  number  of  cases  in  which 
the  vagus  of  one  side  was  excised  with6ut  ill  effect.  Before  operations  in  which  the 
vagus  may  be  irritated  or  divided  he  finds  it  wise  to  administer  i/ioo  grain  of 
atropin  in  order  to  prevent  any  cardiac  or  respiratory  inhibition. 

Hydrocele  of  the  Neck;  Cystic  Lymphangioma. — A  hydrocele  of  the 
neck  consists  of  a  monolocular  or  multilocular  cyst  which  may  extend  into 
the  anterior  mediastinum  or  deep  down  among  the  large  vessels  of  the  neck. 
The  disease  is  congenital.  Of  course,  the  ideal  treatment  is  extirpation,  but 
this  is  rarely  proper  because  of  its  difficulty  and  danger.  If  extirpation  is 
decided  on,  the  operation  ought  to  be  delayed  until  the  end  of  the  first  year  of 
life  (Arrou).  The  most  common  operative  treatment  consists  in  evacuation  by 
trocar  and  cannula,  followed  by  irrigation  with  a  2  per  cent,  solution  of  carbolic 
acid,  or  by  injection  of  tincture  of  iodine  diluted  with  water.  This  simple  treat- 
ment often  gives  excellent  results;  it  is  liable  to  fail  when  there  are  many  com- 
partments or  loculi  in  the  cyst.  WTien  evacuation  and  injection  fail  or  are 
inappropriate,  marsupialization  affords  a  means  of  treatment  which  is  thorough 
and  is  safer  than  extirpation.  Marsupialization  consists  in  incising  the  cyst; 
suturing  the  edges  of  the  wound  in  the  cyst  of  the  skin;  opening  the  subsidiary 
cyst  cavities;  evacuating  all  the  contents  and  providing  for  drainage  by  means 
of  a  gauze  tampon      In  the  course  of  the  operation  part  of  the  cyst-wall  may 


184  EXCISION    OF   CERVICAL   TUMORS. 

be  removed  and  the  interior  of  the  cavity  may  be  swabbed  first  with  liquid 
carbolic  acid  and  then  with  alcohol  to  neutralize  the  carbolic. 

Congenital  cervical  fistulae  require  radical  treatment  when  they  give 
rise  to  much  inflammation  or  to  cystic  tumors;  esthetic  considerations  may 
call  for  their  removal.  Occasionally  the  fistulae  are  shallow  and  their  extir- 
pation is  then  easy.  Usually  they  are  complete,  reaching  from  the  neigh- 
borhood of  the  tonsil  (Rosenmiiller's  fossa  behind  the  tonsil),  passing  under 
the  digastric  muscle  to  penetrate  the  cervical  fascia  and  the  skin  in  almost 
any  location  between  the  stemomastoid  muscles.  Such  fistulae  must  be  com- 
fleiely  excised,  otherwise  recurrence  is  liable  to  take  place.  The  skin-incision 
must  be  extensive  and  the  cord-like  fistulous  track  followed  (preferably  with- 
out being  opened),  under  guidance  of  the  eye,  up  to  its  pharyngeal  termina- 
tion. The  dissection  is  not  one  for  the  tyro  in  surgery  to  attempt.  The  re- 
moval of  the  pharyngeal  end  and  closure  of  the  pharyngeal  wound  are  most 
diflicult,  but  this  difficulty  has  been  evaded  in  a  most  ingenious  manner  by 
Fritz  Konig.  After  the  fistula  has  been  mobilized  to  a  point  above  the  digas- 
tric muscle,  Konig  separates  is  still  further  from  its  surroundings  by  blunt 
dissection  until  the  pharyngeal  mucous  membrane  is  nearly  reached;  then  he 
opens  the  mouth  with  a  Whitehead  speculum,  passes  a  stout  probe  with  an  eye 
on  the  proximal  end  through  the  wound,  and  makes  its  point  appear  elevating 
the  mucous  membrane  in  front  of  the  lower  margin  of  the  tonsil.  An  incision 
made  through  the  mouth  over  the  end  of  the  probe  permits  the  latter  to  be  pulled 
through,  and  with  it  a  thread  of  silk.  The  end  of  the  fistula,  after  being  tied 
to  the  thread,  is  easily  pulled  into  the  mouth,  fastened  by  a  couple  of  stitches 
to  the  wound  in  the  mucosa,  and  its  free  end  cut  away.  The  external  wound 
is  now  closed.  Instead  of  a  long  fistula  leading  from  the  pharynx  to  the  skin, 
there  is  a  short,  harmless  fistula  leading  from  the  back  to  the  front  of  the 
tonsil.     This  simple  "dodge"  of  Konig's  is  one  of  great  value. 

Median  cervical  fistulae  are  different  from  those  alluded  to  above;  they 
are  the  result  of  non-obliteration  of  the  thyroglossal  duct.  The  thy ro glossal 
duct  leads  from  the  foramen  caecum  on  the  tongue  through  the  root  of  that 
organ  down  to  a  low  point  in  the  neck.  On  its  way  down  the  duct  either  passes 
through  or  is  closely  connected  with  the  body  of  the  hyoid  bone.  Excision 
of  a  patent  or  inflamed  duct  below  the  hyoid  is  easy;  above  that  bone,  it  may 
be  difficult  or  easy,  generally  the  former.  If  the  duct  passes  through  the 
hyoid,  the  portion  enclosed  in  the  bone  must  be  thoroughly  removed  even 
if  it  is  necessary  to  excise  a  portion  of  the  bone  itself.  Occasionally  that 
part  of  the  duct  which  traverses  the  tongue  gives  rise  to  a  tumor  consisting 
of  tissue  very  like  that  of  the  thyroid  gland.  Such  tumors  are  usually  easily 
shelled  out  of  the  tongue.  Cysts  arising  from  distention  of  the  duct  above 
the  hyoid  may  give  rise  to  ranula-like  tumors.  In  treatment  of  ranula  it  is 
well  to  bear  this  fact  in  mind.  A  stubborn  and  obscure  recurrent  phleg- 
monous inflammation  in  the  submental  region  may  be  due  to  an  unsuspected 
remnant  of  the  thyroglossal  duct. 


CHAPTER  XX. 
EXCISION  OF  THE  CERVICAL  SYMPATHETIC. 

Jonnesco  describes  the  total  excision  of  the  cervical  sympathetic  very 
nearly  as  follows: 

Step  I. — Cutaneous  incision:  Make  a  cut  from  behind  the  mastoid  process 
downwards  along  the  posterior  border  of  the  sternomastoid  to  a  point  a  little 
below  the  clavicle.     The  external  jugular  vein  is  divided  between  two  ligatures. 

Step  2. — Separation  of  the  posterior  border  of  the  sternomastoid:  To  avoid 
section  of  the  external  branch  of  the  spinal  accessory  nerve  and  the  diffi- 
culties often  met  in  freeing  the  posterior  border  of  the  muscle  in  the  upper  part 
of  the  wound,  make  an  incision  along  the  muscle  parallel  and  close  to  the 
posterior  margin.  Separate  the  fibres  of  the  muscle  and  operate  through  this 
elongated  button-hole. 

Step  3. — Search  for  and  isolation  of  the  sympathetic  nerve:  Retract  the 
muscle  and  with  it  the  packet  of  cervical  vessels  and  nerves  (carotid  artery, 
internal  jugular  veins,  vagus  nerve)  inwards  and  upwards.  Two  blunt  hooks 
or  one  wide  blunt  retractor  are  useful  for  this  purpose.  Look  for  the  nerve 
in  the  middle  of  the  wound,  either  on  the  posterior  surface  of  the  sheath  of 
the  vascular  packet  with  which  the  nerve  may  have  been  retracted  inwards 
or  on  the  vertebral  column,  where  it  lies  in  a  special  aponeurotic  sheath.  The 
nerve  is  easily  found.  It  is  impossible  to  confound  it  with  the  vagus,  the 
descending  branch  of  the  hypoglossal  (descendens  noni),  or  the  phrenic.  To 
dispel  all  doubt  as  to  identity  follow  the  nerve  upwards  and  see  the  superior 
ganglion   (Fig.    282). 

Step  4. — Isolation  and  resection  of  the  superior  ganglion:  Follow  the  nerve- 
trunk  upwards  to  the  ganglion  and  isolate  the  latter  from  below  upwards 
by  blunt  dissection  with  a  director.  Divide  its  afferent  and  efferent  fibres  with 
blunt-pointed  curved  scissors.  When  the  upper  end  of  the  ganglion  is 
isolated,  divide  or  tear  away  the  trunk  which  leads  from  it  towards  the  skull 
(Fig.  283). 

Step  5. — Liberation  of  the  inferior  thyroid  artery:  This  artery  is  surrounded 
by  a  dense  and  often  adherent  nervous  plexus  consisting  of  the  sympathetic 
trunk  and  its'  branches.  The  nerve  often  is  swollen  at  this  point,  forming 
the  middle  cerA'ical  ganglion.  Put  tension  on  the  nerve-trunk  already  isolated 
and  follow  it  downwards.  Elevate  the  nerve  and  the  inferior  thyroid  artery 
together  and  separate  them  by  careful  blunt  dissection   (Fig.   284). 

Step  6. — Isolation  and  resection  of  the  inferior  ganglion:  This  is  the  most 
difficult  step  in  the  operation,  as  the  ganglion  lies  deeply  imbedded  in  a  special 

185 


i86 


EXCISION   OF   THE    CERVICAL   SYMPATHETIC. 


lodge  at  the  base  of  the  neck  or  even  in  the  thorax,  behind  the  clavicle,  against 
the  neck  and  head  of  the  first  rib,  between  the  scalenus  anticus  and  longus 
colli  muscles,  and  just  above  the  pleura.  Using  the  trunk  of  the  nerve  as  a 
guide,  penetrate  to  the  ganglion,  which  lies  sometimes  internal  to,  and  some- 
times (though  rarely)  external  to,  the  vertebral  artery.  The  ganglion  is 
adherent  to  the  artery  and  enlaces  it  in  a  raeshwork  of  its  efferent  and  afferent 
fibres  (Fig.  284).  With  appropriate  retractors  retract  the  scalenus  anticus, 
thyroid  axis,  and  the  vertebral  artery  and  vein,  downwards  and  outwards; 
retract  inwards  and  forwards  the  sternomastoid  muscle  and  the  carotid  sheath 


Sup.  ganglion 

Sp.  accesssry  nerve 

Sternomastoir" 

Cartoid  packet  i 


Sympath.  n. 


Inf.  thyroid  artery  • 


Inf.  ganglion 
Vertebral  artery 


Phrenic  n. 


Fig.  282. —  {Jonnesco.) 

with  its  contents.  Divide,  with  a  grooved  director,  the  cellular  and  aponeurotic 
tissues  covering  the  vessels  and  the  ganglion.  Seize  the  ganglion  with  for- 
ceps and  isolate  it  successively  from  the  vertebral  artery  externally  and  from 
the  rib  and  spine  internally.  Isolate  and  divide  the  afferent  and  efferent 
fibres,  and  remove  the  ganglion. 

The  dangers  which  may  be  encountered  are: 

1.  Injury  to  the  vertebral  artery  and  vein. 

2.  Injury  to  the  first  intercostal  artery  or  its  cervical  branch, 

3.  Injury  to  the  subclavian  artery,  especially  on  the  left  side. 

4.  Injury  to  the  pleura. 

5.  Friability  of  the  ganglion,  rendering  morcellement  necessary. 

6.  Intimate   union   of   the   inferior  cervical  and  first  thoracic  ganglia  into 
one  mass,  from  which  a  portion  must  be  removed. 


EXCISION    OF   CERVICAL   SYMPATHETIC. 


187 


7.  Injury  to  the  retroclavicular  venous  plexus.  This  accident  will  be 
rare  if  the  trunk  of  the  nerve  is  followed  closely. 

Step  7. — Suture  oj  the  Wound. — Close  the  wound  completely  with  buried  and 
superficial  catgut  sutures.  The  superficial  stitches  ought  to  be  introduced 
in  the  intradermic  fashion  so  as  to  leave  little  scar.  There  should  be  no  drain- 
age.    Apply  dressings. 


Sympath.  n. 


Inf. thyroid  arter\%  -  -  --wr  ^f ' 
Middle  ganglion"  -  •  -    - 


-        Scalenus  ant. 
'.    Thoroid  axis 


Vertebral  vein 
Fig.  283. — {Jonnesco.) 


Inf.  thyroid  art. 


Middle  gang! 


Inferior  ganglio:.- 


Verteoral  art.  and 
vein 


Ventebral  n. 

Fig.  284. — (Jonnesco.) 


Immediately  after  operation  on  one  side  the  corresponding  pupil  dilates, 
the  face  flushes,  eye  waters,  and  nose  secretes  abundantly.  These  phenomena, 
except  the  pupillary  dilatation,  are  very  transitory.  The  pulse  falls  below 
normal  for  a  few  days;  after  partial  resection  of  the  sympathetic  it  is  acceler- 
ated.    The  operation  seems  to  have  no  ill  effects. 


1 88  EXCISION    OF   THE   CERVICAL   SYMPATHETIC. 

After  the  patient  has  recovered  from  the  operation  on  one  side  the  other 
side  should  be  attacked  in  the  same  manner. 

Jonnesco  ("German  Surg.  Congress,"  1906)  has  performed  cervical 
sympathectomy  in  159  cases,  in  141  of  these  the  three  gangha  were  removed 
with  or  without  the  first  thoracic  ganglion.  In  all  but  two  cases  the  operation 
was  bilateral.  There  were  no  deaths  and  no  secondary  trophic  troubles.  The 
therapeutic  results  were: 

1.  Twenty-five  cases  of  exophthalmic  goitre  (two  subtotal  resections; 
twelve  complete;  eleven  cervico-thoracic  resections).  In  every  case  the  dis- 
ease was  primary  Basedow's  disease,  either  complete  or  incomplete,  often  of 
serious  degree.  All  the  patients  recovered,  every  symptom  disappearing. 
He  recommends  strongly  the  complete  operation  with  or  without  removal 
of  the  first  thoracic  ganglion. 

2.  Glaucoma. — Eighty-eight  cases  of  superior  sympathectomy  have  been 
collected  showing  sixty-one  cured  or  improved,  twenty-two  unimproved, 
five  aggravated. 

3.  Epilepsy. — One  hundred  and  seventeen  cases  with  but  twelve  definite 
cures. 

4.  Trigeminal  Neuralgia. — In  one  case  resection  of  the  superior  ganglion 
resulted  in  recovery  which  has  lasted  four  years,  in  another  case  for  six  months. 

De  Souza  has  had  similar  experiences  in  Basedow's  disease  and  in  facial 
neuralgia. 

Farquhar  Curtis  finds  that  the  mortality  after  sympathectomy  for  Basedow's 
disease  is  very  high  and  the  ultimate  results  in  the  survivors  fair.  ("Annals 
Surg.,"  March,  1906.)  Alexander  of  Liverpool  at  one  time  performed  sym- 
pathectomy frequently  for  epilepsy  but  gave  it  up.  The  operation  is  still 
sub  judice,  but  most  surgeons  are  sceptical  or  more  than  sceptical  of  its  value. 


CHAPTER  XXI. 

RETROPHARYNGEAL  ABSCESS  AND  TUMORS. 

There  are  two  methods  of  opening  retropharyngeal  abscess,  viz.,  through 
the  mouth  and  through  the  neck. 

1.  Opening  the  Abscess  through  the  Mouth. — No  anaesthetic,  not  even 
cocaine,  is  permissible.  If  the  pharynx  and  larynx  were  anaesthetized,  there 
would  be  increased  danger  from  inspiration  of  discharges.  A  knife,  the 
edge  of  which  is  protected  with  cotton  or  adhesive  plaster  to  within  one  inch 
of  the  point,  is  guided  on  the  finger  of  the  left  hand  through  the  mouth  to  the 
posterior  wall  of  the  pharynx.  An  incision  is  made  into  the  abscess  at  its  most 
prominent  point.  The  knife  is  at  once  withdrawn.  If  the  patient  is  a  child, 
the  operation  should  be  performed  in  the  Rose's  position — i.  e.,  with  hanging 
head,  and  m  any  case  as  soon  as  pus  begins  to  flow  the  head  should  be  lowered 
and  the  body  elevated.  The  after-treatment  consists  in  the  use  of  antiseptic 
gargles  and  sprays  and  in  keeping  the  wound  open  by  daily  probing,  if  this 
is  necessary. 

2.  Drainage  through  the  Neck. — Chiene's  Operation. — Make  an  inci- 
sion two  inches  in  length  along  the  posterior  margin  of  the  sternomastoid,  be- 
ginning at  the  apex  of  the  mastoid  process  and  running  downwards.  After 
division  of  the  deep  fascia  one  can  by  blunt  dissection  reach  the  anterior  sur- 
face of  the  bodies  of  the  cervical  vertebrae  where  the  abscess  is  situated.  The 
skin  and  fascia  having  been  incised  as  above,  the  pus  may  be  reached  and 
evacuated  by  Hilton's  method.     This  is  a  very  safe  and  easy  procedure. 

Remarks. — Retropharyngeal  abscess  may  be  acute  or  chronic.  It  is  only 
for  the  former  that  operation  through  the  mouth  is  suitable.  On  purely  theo- 
retical grounds  the  operation  through  the  mouth  must  be  condemned  for  the 
following  reasons:  (a)  When  the  pus  begins  to  flow  there  is  danger  of  asphyx- 
iation. (6)  No  dressings  can  be  applied  to  soak  up  discharges  and  keep 
out  dirt,  (c)  There  is  grave  danger  of  septic  pneumonia  and  of  infection  to 
the  gastrointestinal  canal,  (d)  If  the  case  is  one  of  tuberculous  abscess, 
secondary  infection  is  certain.  Practically  it  has  been  found  that  by  using 
Rose's  position  or  by  inverting  the  patient  during  the  first  flow  of  pus  the  dan- 
ger of  asphyxiation  is  averted,  and  that  in  acute  cases  rapid  recovery  does  en- 
sue. An  advantage  is  claimed  for  this  operation,  viz.,  that  an  anaesthetic 
is  not  necessary,  but  certainly  in  case  of  need  the  external  operation  can  be 
done  under  a  local  anaesthetic. 

The  advantages  of  the  external  route  are:     (a)  The  possibility  of  careful 

189 


ipo  RETROPHARYNGEAL  ABSCESS  AND    TUMORS. 

removal  of  diseased  foci,  e.  g.,  diseased  bone,  etc.;  (b)  the  possibility  of  treat- 
ing the  abscess  antiseptically  and  providing  for  permanent  draining;  (c)  the 
possibility  of  avoiding  secondary  infection;  (d)  the  avoidance  of  the  danger 
of  drowning  the  patient  in  his  own  pus. 

The  principal  disadvantage  is  the  scar  which  must  be  left,  but  as  a  rule  it 

is  not  very  noticeable.  1 y^ 

Retropharyngeal  Tumors. — I.  The  tumor  is  not  adherent  to  the  spinal 

column,    but   is   movable.     Perform   tracheotomy.     Tampon   the   larynx   or 

trachea.     Place  the  patient  in  Rose's  position.     Introduce  a  mouth-gag  and 

open  the  mouth.     Pierce  the  tongue  with  a  needle  and  pull  through  a  stout 

thread  which  serves  as  a  handle  to  manipulate  the  tongue.     Make  an  incision 

through  the  mucous  membrane  of  the  posterior  pharyngeal  wall  and  expose 

the   tumor  freely.     Busch  has  shown  that  the  tumor 

lies  loosely  imbedded  in   the    retropharyngeal    tissues 

and  can  be  shelled  out.     Generally  blunt  dissection 

with  closed  curved  scissors  will  result  in  easy  removal 

of  the  growth.     Clean  the  pharyngeal  cavity  and  the 

wound  with  a  non-poisonous  antiseptic. 

Fig.  285.  If  necessary  to  obtain  more  room,  the  soft  palate 

may  be  divided  longitudinally.     This  wound  must  be 

closed  by  suture  as  soon  as  the  tumor  is  removed. 

II.  The  tumor  is  so  extensive  that  removal  through  the  mouth  is  impossi- 
ble.    The  pharynx  must  be  opened  from  the  neck. 

Step  I. — Make  a  U-shaped  incision  beginning  in  front  of  the  masseter 
and  ending  at  the  tip  of  the  mastoid  process.  The  lowest  part  of  the  U  reaches 
below  the  level  of  the  hyoid  bone.  Doubly  ligate  and  divide  the  external 
jugular  vein.  Reflect  upwards  the  skin-flap  outlined  by  the  incision(  Fig.  285). 
Step  2. — Divide  the  cervical  fascia  along  the  anterior  margin  of  the  sterno- 
mastoid.  Expose  the  external  carotid  artery.  This  artery,  partly  covered 
by  the  internal  jugular  vein,  should  be  sought  on  the  line  of  the  anterior  margin 
of  the  sternomastoid  between  a  point  on  a  level  with  the  hyoid  and  one  on  a 
level  with  the  upper  edge  of  the  thyroid  cartilage.  Before  tying  the  vessel 
expose  at  least  one  of  its  branches.  This  precaution  is  recommended  because 
the  internal  has  occasionally  been  mistaken  for  the  external  carotid. 

Step  3. — Doubly  ligate  the  artery  and  divide  it  between  the  ligatures.  Ex- 
pose as  thoroughly  as  possible  such  part  of  the  tumor  as  may  present  between 
the  inferior  maxilla  and  the  mastoid.  If  it  is  feasible  to  remove  the  tumor 
through  this  space,  do  so;  otherwise  proceed  to  the  next  step. 

Step  4. — Cut  through  the  soft  structures  covering  the  inferior  edge  of 
the  horizontal  ramus  of  the  lower  jaw  at  a  point  just  in  front  of  the  masseter 
muscle.  Through  this  incision  with  an  elevator  separate  the  periosteum 
from  the  bone  sufficient  to  allow  of  subperiosteal  section  of  the  bone.  With 
finger  saw,  forceps,  Gigli's  vnre  or  the  chain  saw  divide  the  bone.  Dislocate 
the  temporo-maxillary  joint  and  turn  the  ascending  ramus  of  the  jaw  upwards 


RETROPHARYNGEAL  ABSCESS  AND   TUMORS.  I9I 

together  with  the  soft  parts  covering  it.  This  gives  very  free  access  to  the 
pharyngeal   wall. 

Step  5. — Isolate  the  tumor  by  blunt  dissection  if  possible.  Do  not  open 
the  pharyngeal  cavity  before  it  is  absolutely  necessary  to  do  so.  Remove 
the  growth 

Step  ^'.-T^Pack  the  cavity  with  iodoform  gauze.  Replace  the  dislocated 
portion  of  the  lower  jaw  and  wire  it  in  position.  Close  most  of  the  wound 
in  the  soft  parts  by  interrupted  silkworm-gut  sutures,  leaving  an  opening 
through  which  the  gauze  pack  protrudes.     Dress. 

In  one  case  the  writer  was  surprised  to  find  that  he  was  able  to  shell  out 
in  the  above  manner  a  large  tumor  affecting  the  right  side  and  roof  of  the 
pharynx,  without  tearing  or  dividing  the  phar}'ngeal  mucous  membrane. 

As  a  preliminary  to  the  operation  tracheotomy  may  or  may  not  be  per- 
formed. If  the  growth,  either  from  size  or  location,  does  not  interfere  with 
respiration;  if  the  surgeon  ligates  the  external  carotid  artery  near  its  origin 
and  does  not  open  the  pharynx  until  the  tumor  is  almost  entirely  separated 
and  hemostasis  has  been  secured,  then  a  preliminary  tracheotomy  appears 
superfluous. 


CHAPTER  XXII. 
(ESOPHAGUS. 

CEsophagotomy. — The  oesophagus  may  be  opened  either  in  the  neck 
or  in  the  posterior  mediastinum.     The  latter  operation  is  discussed  elsewhere. 

Cervical  oesophagotomy  is  performed  for  the  removal  of  foreign  bodies, 
the  treatment  of  stricture,  the  excision  of  small,  sharply  defined  tumors,  or  as  a 
step  in  the  operation  of  oesophagostomy.  Place  the  patient  on  the  table  with 
shoulders  slightly  elevated  and  the  face  turned  towards  the  right.  Beginning 
at  the  level  of  the  thyroid  cartilage,  make  an  incision  downwards  for  about 
three  inches  along  the  anterior  margin  of  the  left  sternomastoid  muscle.  Divide 
the  platysma,  superficial  and  deep  fasciae.  The  omohyoid  may  be  divided 
or  retracted  according  to  convenience.  Retract  the  thyroid  gland  and  trachea 
towards  the  right.  Notice,  in  the  wound,  the  common  sheath  containing  the 
carotid,  internal  jugular,  and  vagus.  Retract  these  structures  to  the  left. 
The  oesophagus  will  now  be  exposed.  If  a  foreign  body  is  present,  fix  the 
oesophagus  with  small  volsellum  forceps  and  make  a  longitudinal  cut  into  it 
over  the  foreign  body.  If  necessary,  enlarge  the  wound  with  a  probe-pointed 
bistoury  or  with  scissors.  Gently  extract  the  foreign  body.  This  frequently 
requires  much  patience.  The  incision  through  the  oesophagus  should  be 
made  on  the  side,  as  the  recurrent  laryngeal  lies  in  the  groove  between  it  and 
the  trachea. 

When  no  foreign  body  is  present  distending  the  oesophagus,  pass  an 
oesophageal  bougie  through  the  mouth  and  cut  down  upon  it  when  incising 
the  gullet  wall. 

Haecker  (Muenchener  med.  Woch.,  Oct.  15,  1907)  reports  the  case  of  a 
pregnant  woman  who  swallowed  her  plate  with  artificial  teeth.  This  irregu- 
lar body  became  impacted  where  the  oesophagus  crosses  the  left  bronchus. 
Attempts  at  removal  by  the  oesophagoscope  having  failed,  Friedrich  opened 
the  oesophagus  just  above  the  upper  thoracic  aperture  and  removed  the  plate 
after  dividing  it  with  cutting  forceps.  The  wound  was  packed  around  an 
oesophageal  catheter  through  which  food  was  administered.  Soon  an  oesopha- 
geal-bronchial  fistula  formed  and  gangrene  developed.  Gastrostomy  was 
now  performed  and  for  three  months  the  patient  was  nourished  through  the 
gastric  fistula.  After  this  time  the  broncho-oesophageal  fistula  closed  and  the 
patient  recovered  perfectly. 

Bodies  impacted  low  down  in  the  oesophagus  have  been  extracted  through 
a  gastrotomy  wound  in  twenty  out  of  twenty-four  cases  (v.  Haecker).  A 
bougie  passed  through  the  mouth  gives  great  assistance  in  the  work. 

192 


(ESOPHAGEAL    DIVERTICULA.  1 93 

Foreign  bodies  may  be  removed  from  the  lower  oesophagus  through  the 
stomach.  M.  H.  Richardson  successfully  performed  gastrotomy,  explored 
the  lower  oesophagus  and  removed  a  plate  containing  four  teeth  which  had 
been  lodged  there  for  eleven  months.  A  peach  stone  was  arrested  6  or  7 
inches  above  the  cardiac  orifice;  the  usual  measures  failed  to  dislodge  it; 
W.  T.  Bull  performed  gastrotomy,  passed  a  small  bougie,  with  a  loop  at  its 
point,  from  the  stomach  to  the  mouth,  pulled  a  stout  thread  through  the 
oesophagus  mth  the  bougie;  tied  a  sponge  to  the  lower  end  of  the  thread  and 
pulled  the  sponge  through  the  oesophagus  and  out  of  the  mouth.  The  sponge 
swept  away  the  foreign  body. 

Through  the  oesophageal  wound  one  may  divide  or  forcibly  dilate  a  stric- 
ture or  even  remove  a  small  tumor.  For  such  purposes,  however,  the  opera- 
tion will  be  but  little  used,  as  strictures  are  generally  more  suitably  treated  by 
other  means,  and  tumors  eradicable  by  the  above  operation  must  be  of  great 
rarity. 

Closure  of  the  Wound. — Close  the  oesophageal  wound  by  a  row  of  sutures 
of  fine  catgut  not  involving  the  mucosa.  Lessen  the  size  of  the  external  wound 
by  a  few  stitches  at  its  upper  and  lower  extremities.  Loosely  pack  the  remain- 
der of  the  wound  with  iodoform  gauze.  Apply  plentiful  dressings.  Treves 
advises  the  use  of  some  orthopaedic  apparatus  to  secure  rest  for  the  parts. 

For  the  first  day  or  two  after  the  operation  the  patient  should  be  nourished 
by  means  of  enemata;  subsequently  food  should  be  administered  through  a 
small  soft-rubber  stomach-tube  passed  through  the  mouth.  This  method 
of  feeding  must  be  kept  up  until  it  is  evident  that  the  oesophageal  wound  has 
healed.  The  cervical  wound  requires  frequent  dressing  and  the  mouth  must 
be  washed  at  short  intervals  with  some  antiseptic  lotion.  The  great  danger 
to  be  apprehended  is  sepsis,  especially  septic  mediastinitis. 

(Esophageal  Diverticula. — Diverticula  occasionally  are  present  in  the 
neck  and  communicate  with  the  oesophagus  or  pharynx.  When  these  are  large, 
food  passes  into  them  and  serious  symptoms,  even  death,  may  result.  The 
condition  is  often  unrecognized  by  the  physician.  In  serious  cases  operation 
is  demanded.  Sometimes  good  results  are  obtained  by  having  the  patient 
swallow  a  whip  cord  and  using  this  as  a  guide,  passing  bougies  in  a  manner 
analogous  to  the  passage  of  Gouley's  tunnelled  sounds  over  a  whalebone  fili- 
form in  urethral  stricture  (Mixter). 

The  Operation. — Proceed  as  in  oesophagotomy.  Retract  the  trachea 
towards  the  right,  the  sternomastoid  and  the  sheath  containing  the  carotid, 
internal  jugular,  and  vagus  to  the  left.  Pass  an  oesophageal  bougie  through 
the  mouth  into  the  diverticulum,  if  this  is  possible.  Recognize  the  divertic- 
ulum and  its  relations  to  surrounding  structures.  Remove  the  bougie.  Sepa- 
rate the  diverticulum  from  its  surroundings.  This  can  generally  be  accom- 
plished by  blunt  dissection.  Where  the  diverticulum  joins  the  oeosphagus 
its  neck  may  be  as  thick  as  a  man's  thumb.  Divide  the  neck  of  the  diver- 
ticulum layer  by  layer  close  to  the  oesophagus.  With  catgut,  suture  the  wound 
13 


194  CESOPHAGUS. 

of  the  mucous  membrane.  The  wound  of  the  outer  tunics  of  the  neck  of  the 
diverticulum  is  closed  by  an  invaginating  suture  like  Lembert's  intestinal 
stitch.  Partially  close  the  external  wound.  Provide  very  free  drainage  by 
means  of  iodoform  gauze.  The  after-treatment  is  the  same  as  that  for 
oesophagotomy.  When  the  diverticulum  is  comparatively  small  the  skin- 
incision  need  not  be  longer  than  that  for  oesophagotomy;  but  when  it  is  large, 
then  the  incision  must  be  longer.  It  is  better  to  make  an  incision  longer  than 
is  absolutely  necessary  than  to  be  cramped,  while  operating,  through  lack  of 
room. 

Girard  and  A.  E.  Halstead  in  cases  of  small  diverticula  avoid  opening  the 
sac.  After  exposing  and  isolating  the  sac,  they  surround  it  near  its  base  by 
a  catgut  purse-string  suture,  invaginate  the  diverticulum  mto  the  oesophagus, 
pull  the  purse  string  tight  and  tie  it.  This  method  avoids  the  necessity  of 
drainage.     The  pouch  is  said  to  become  atrophied. 

Gelile's  Method. — To  avoid  dangers  of  mediastinitis,  etc.,  especially  in 
debilitated  individuals,  Gehle  ("Muenchener  med.  Woch.")  operates  as 
follows: 

Expose  and  isolate  the  diverticulum.  Make  a  small  opening  into  the 
distal  end  of  the  sac.  Remove  the  mucous  membrane  as  well  as  possible 
with  a  sharp  spoon.  Through  the  sac  pass  a  small  oesophageal  tube  into  the 
stomach.  Rotate  the  sac  (and  tube)  on  its  long  axis,  to  the  extent  of  180°. 
Fix  the  sac  in  its  position  of  torsion  by  means  of  three  catgut  purse-string 
sutures  after  freshening  the  surfaces  to  be  brought  in  contact.  These  sutures 
tie  the  sac  firmly  to  the  tube.  Suture  the  opening  in  the  sac,  where  the  tube 
protrudes,  to  the  superficial  fascia.  Close  the  wound  around  the  sac.  Gehle 
was  able  to  feed  his  patient  through  the  tube  on  the  day  of  operation.  The 
tube  was  removed  on  the  sixth  day.  On  the  sixteenth  day  both  solid  and 
fluid  food  could  be  swallowed. 

To  the  author  it  appears  that  Gehle  is  wrong  in  calling  the  operation 
"radical,"  but  in  suitable  cases  it  seems  to  be  the  least  dangerous  method  and 
at  the  same  time  the  alteration  in  position  and  shape  of  the  diverticulum 
promises  good  practical  results.  It  is  difficult  to  believe  that  curettement 
will  sufficiently  remove  the  mucosa  to  permit  of  obliteration  of  the  lumen. 

(ESOPHAGEAL  STRICTURE. 

Non-malignant  strictures  of  the  oesophagus  should  be  treated  by  the  passage 
of  bougies  through  the  mouth.  It  is  said  that  dilatation  may  sometimes  be 
aided  by  the  hypodermic  administration  of  suitable  doses  of  thiosinamin 
(thiosinamin,  15;  antipyrin,  7.50;  water,  100.  Dose,  0.5  c.c.  Ten  injections 
usually  suffice)  or  some  of  its  equivalents.  This  drug  acts  by  softening  scar 
tissue  to  such  an  extent  that  mechanical  treatment  is  greatly  facilitated.  The 
oesophagus  commonly  becomes  greatly  distended  above  the  site  of  a  stricture 
hence  it  is  often  difficult  to  pass  a  sound  into  the  stricture.  Under  these  cir- 
cumstances retrograde  catheterization  becomes  proper. 


CESOPHAGEAL    STRICTURE.  I95 

Abbe's  Operation. — The  oesophageal  pouch  which  forms  above  a  stric- 
ture is  a  great  hindrance  to  the  passage  of  bougies.  Abbe  overcomes  this 
difl&culty  by  retrograde  dilatation  which  he  carries  out  in  characteristically 
ingenious  fashion.  Perform  gastrotomy.  Pass  a  fine  whale-bone  bougie 
from  below  upwards  until  it  protrudes  from  the  mouth.  To  the  end  of  the 
bougie  tie  two  long  and  stout  threads  of  braided  silk  (whip  cord  will  do). 
Pull  the  bougie  out  through  the  stomach  wound  and  leave  the  two  threads 
protruding  from  the  mouth  and  the  stomach  wound.  Tie  the  lower  end  of 
one  thread  to  an  eye  at  the  point  of  a  conical  oesophageal  bougie  (Billroth). 
By  pulling  on  the  upper  end  of  this  thread  it  is  easy  to  bring  the  conical  tip  of  the 
bougie  into  the  stricture  and  render  that  stricture  tense.  Keep  up  gentle  traction 
to  dilate  the  stricture  with  the  bougie  and  at  the  same  time  pull  the  second  cord 
upwards  and  downwards  vigorously  with  a  sea-saw  motion.  The  friction  of 
the  cord  divides  the  stricture  without  damaging  other  strictures.  The  conical 
bougie  rapidly  passes  upwards  as  the  friction  wears  away  the  strictures, 
and  the  largest  bougie  suitable  to  the  oesophagus  is  rapidly  forced  upward  to 
the  mouth  by  a  few  moments'  stretching  and  "string-sawing."  The  gastros- 
tomy wound  may  now  be  closed  by  inversion  and  double  suturing.  Subse- 
quent passage  of  a  full-size  bougie  once  a  week  will  complete  the  cure,  but 
must  be  continued  at  longer  intervals  for  one  year  or  more.  Instead  of  divid- 
ing the  stricture  by  friction  and  bougies,  Ochsner  draws  a  rubber  tube,  under 
tension,  through  the  stricture.  When  the  tension  is  taken  off  the  tubing  it 
expands  and  so  dilates  the  stricture.  In  the  course  of  some  days,  during  which 
larger  or  double  tubes  are  introduced,  Ochsner  obtains  good  results. 

The  author  was  much  prejudiced  against  the  Abbe  operation  thinking 
it  harsh  and  dangerous,  but  since  seeing  it  performed  by  Abbe  he  has  changed 
his  views. 

In  any  method  of  treatment  where  a  gastrostomy  is  performed,  do  noi 
administer  thiosinamine.  If  this  drug  has  any  marked  softening  effect  on  the 
scar  tissue  forming  the  stricture  it  ought  to  have  a  similar  and  disastrous  effect 
on  the  union  between  the  stomach  and  the  belly  wall. 

In  one  case  operated  on  by  Maurice  Richardson  a  friable  stricture  existed 
in  the  oesophagus  immediately  below  the  opening  of  a  diverticulum.  Richard- 
son split  or  ruptured  the  stricture  longitudinally  and  repaired  the  defect  by 
means  of  a  flap  provided  by  the  diverticulum.  The  excess  of  tissue  in  the 
diverticulum  was  excised. 


CHAPTER  XXIII. 

PHARYNGOTOMY,  LARYNGOTOMY,  PARTIAL 
LARYNGECTOMY,  AND  LARYNGECTOMY. 

SUBHYOID  PHARYNGOTOMY. 

Place  the  patient  on  his  back,  the  shoulders  supported  on  a  cushion  and 
the  head  extended.     Palpate  the  hyoid  bone  and  thyroid  cartilage. 

Step  I. — Make  a  transverse  cutaneous  incision  immediately  below  and 
parallel  to  the  hyoid  bone.  If  the  operation  is  for  the  purpose  of  exposing 
the  entrance  to  the  larynx,  an  incision  two  inches  in  length  is  sufficient;  if  for 
the  removal  of  a  tumor  of  the  pharynx  or  upper  larynx,  the  incision  must  be 
much  longer. 

Step  2. — Divide  the  platysma  myoides,  and  omohyoid,  sternohyoid,  and 
thyrohyoid  muscles  close  to  the  hyoid  bone,  but  leaving  sufficient  of  their 
substances  attached  to  the  bone  to  permit  of  their  union  by  suture. 

Step  3. — Divide  the  thyrohyoid  membrane  along  the  posterior  surface 
of  the  hyoid,  the  knife  being  directed  backwards  and  upwards.  Leave  enough 
membrane  attached  to  the  bone  to  permit  the  use  of  sutures  when  closing 
the  wound.     Attend  to  hemostasis. 

Step  4. — The  mucosa  now  pouts  into  the  wound  during  expiration;  seize  it 
with  forceps  and  divide  it.  Be  careful  not  to  injure  the  epiglottis.  Insert 
two  catgut  sutures  into  the  upper  edge  of  the  wound  in  the  mucosa  to  act  as 
guides  or  tractors  when  closure  is  begun.  Pull  the  epiglottis  out  of  the  wound 
and  insert  into  it  a  suture  to  be  used  as  a  tractor.  The  upper  part  of  the 
larynx  and  the  lower  pharynx  now  lie  exposed,  and  one  may  proceed  to  re- 
move any  foreign  body  or  accessible  tumor.  If  the  operation  is  done  for 
malignant  disease  of  the  upper  zone  of  the  larynx  (extrinsic  disease — Semon), 
or  if  any  hemorrhage  is  anticipated,  it  is  well  to  perform  a  preliminary 
tracheotomy. 

Step  5. — Close  the  wound  in  the  mucosa  ^\^th  fine  catgut  sutures.  Unite 
the  thyrohyoid  membrane,  the  divided  muscles,  and  the  skin  each  by  a  separate 
layer  of  sutures.  Insert  a  small  drain  of  gauze  or  oiled  silk  down  to  the  line 
of  suture,  closing  the  wound  in  the  mucosa.  If  a  large  part  of  the  pharynx 
has  been  excised,  it  is  wise  to  pack  the  cavity  with  gauze  and  only  partially 
close  the  wound  'with  sutures;  under  these  circumstances  a  tracheotomy  will 
have  been  performed. 

TRANSHYOID  PHARYNGOTOMY. 

Vallas  obtains  access  to  the  pharynx  by  a  median  incision. 
Step  I. — Make  a  median  cutaneous  incision  from  a  point  one  finger-breadth 

196 


LARYNGOTOMY.  197 

above  the  hyoid  to  the  thyroid  notch.  Divide  the  skin,  subcutaneous  tissue, 
etc.,  and  separate  the  mylohyoid  muscles. 

Step  2. — Denude  a  small  portion  of  the  hyoid  bone  in  the  middle  line  and 
divide  the  bone  with  scissors  or  forceps.  Retract  the  two  halves  of  the  hyoid 
and  the  attached  soft  structures.  This  gives  a  space  about  i  1/2  inches  in 
width,  and  exposes  the  mucous  membrane  of  the  phar}'nx  above  and  the 
thyrohyoid  membrane  below  the  bone. 

Step  3. — Guided  by  a  finger  passed  into  the  pharynx  through  the  mouth 
open  the  pharynx,  cutting  from  above  downwards. 

Step  4. — Having  attended  to  the  disease  which  necessitated  operation, 
close  the  wound  with  several  layers  of  suture,  after  providing  for  drainage. 
It  is  unnecessary  to  suture  the  hyoid  bone. 

SUPRAHYOID  PHARYNGOTOMY. 

Eremitsch,  Griinwald,  Fedoroff  and  others  recommend  suprahyoid  pharyn- 
gotomy  as  a  means  of  access  to  tumors,  especially  to  those  at  the  base  of  the 
tongue  or  on  the  epiglottis.  Preliminary  tracheotomy  is  unnecessary.  Place 
the  patient  on  his  back.     Support  the  shoulders  letting  the  head  fall  backwards. 

Step  I. — Make  a  transverse  incision,  concave  upwards  about  1/4  inch 
above  the  hyoid.     Divide  the  skin  and  platysma. 

Step  2. — Retract  the  submaxillary  glands  which  present.  Find  the  inser- 
tions of  the  digastric  muscles  and  preserve  them.  Divide  transversely  the 
mylohyoids,  geniohyoids  and  hyoglossi.  Open  the  pharynx,  being  careful 
not  to  injure  the  epiglottis.  The  pharynx,  soft  palate,  tonsils,  epiglottis  and 
the  base  of  the  tongue  are  well  exposed.  In  order  to  operate  on  the  base  of 
the  tongue  the  posterior  half  of  the  tongue  must  be  pulled  into  the  wound 
by  means  of  a  sharp  retractor. 

INTERCRICOTHYROTOMY.     LARYNGOTOMY. 

This  operation  is  commonly  employed  as  a  safe  substitue  for  tracheotomy 
as  a  preliminary  to  operations  upon  the  tongue.  Butlin  is  an  enthusiastic 
advocate  of  the  operation  which  he  uses  in  all  such  procedures  as  excision 
of  the  tongue,  of  the  upper  jaw,  etc.  It  only  consumes  about  one  minute  of 
time  and  renders  easy  work  which  would  otherwise  be  troublesome. 

Place  the  patient  on  his  back  with  head  thrown  back  and  the  neck  sup- 
ported on  a  firm  pillow.     Identify  the  thyroid  and  cricoid  cartilages  by  touch. 

Step  I. — With  finger  and  thumb  hold  the  larynx  steady.  Make  an  inci- 
sion I  1/2  inches  long  in  the  middle  line  over  the  lower  part  of  the  thyroid,' 
the  cricothyroid  interval,  and  the  cricoid.  Retract  the  edges  of  the  wound. 
Expose  the  cricothyroid  membrane.     Attend  to  hemostasis. 

Step  2.— Divide  the  cricothyroid  membrane  transversely  just  above  the 
cricoid  cartilage  and  so  avoid  injur)'  to  the  vocal  cords  and  the  cricothyroid 


198 


PHARYNGOTOMY  AND  LARYNGOTOMY. 


vessels.  Penetrate  the  mucous  membrane.  Pass  a  closed  forceps  through 
the  wound  in  the  mucosa  and  open  the  blades  so  as  to  dilate  the  wound. 

Step  3. — Pass  a  Butlin's  laryngotomy  cannula  into  the  cavity  of  the  larynx. 
The  error  has  been  made  of  passing  the  cannula  (Fig.  286)  into  the  cellular 
tissue  with  nasty  results.  Fix  the  cannula  in  place  by  tapes  passed  around 
the  neck. 

It  is  easy  to  administer  an  anaesthetic  through  the  cannula.  After  the 
operation  on  the  tongue  or  mouth  is  completed  the  cannula  may  be  removed 
as  soon  as  the  patient  is  put  to  bed.  No  stitches  are  required  to  close  the 
wound. 


Fig.  286. — Butlin's  Laryngotomy  Cannula. 

X.  Silver  tube  inserted  into  cannula.     On  this  is  it  easy  to  fix  a  rubber  tube  through  which  the 

anaesthetic  can  be  administered. 


LARYNGOTOMY  AND  PARTIAL  LARYNGECTOMY. 

Laryngotomy  is  an  operation  in  which  the  larynx  is  split  open,  its  interior 
exposed,  and  any  foreign  body  or  disease  removed.  The  operation  is  fre- 
quently accompanied  by  partial  laryngectomy. 

The  Operation. — Step  i. — Perform  a  low  tracheotomy.  Insert  a  Tren- 
delenburg or  a  Hahn  cannula. 

Step  2. — Make  a  median  incision  from  a  point  immediately  below  the 
hyoid  bone  to  one  just  below  the  cricoid  cartilage.  Divide  the  cervical  fascia 
to  the  full  extent  of  the  wound.  Separate  the  sternohyoid  muscles  by  blunt 
dissection. 

Step  3. — Incise  the  cricothyroid  membrane  after  fixing  the  cricoid  carti- 
lage with  a  sharp  hook  or  small  volsellum  forceps.  With  a  probe-pointed 
strong  knife,  with  strong  scissors,  or  with  thin-bladed  bone  forceps  divide 
the  thyroid  cartilage  accurately  in  the  middle  line.  When  the  cartilage  is 
very  hard,  Treves  advises  the  use  of  a  fine  saw  instead  of  the  bone  forceps.  In 
such  cases  probably  it  might  be  easier  and  less  damaging  to  pass  a  Gigli  wire 


LARYNGECTOMY.  I 99 

saw  through  the  wound  in  the  cricothyroid  membrane,  behind  the  thyroid 
cartilage  and  out  through  a  cut  in  the  thyrohyoid  membrane,  and  saw  through 
the  cartilage  in  the  middle  line  from  within  outwards. 

Step  4. — Retract  the  lateral  halves  of  the  thyroid  cartilage  with  sharp  hooks. 

Step  5. — Remove  the  foreign  body  or  tumor  or  excise  the  laryngeal  contents 
completely. 

Step  6. — Either  completely  or  partially  close  the  larynx  with  sutures.  Par- 
tial closure,  a  gauze  wick  being  left  for  twenty-four  hours  to  drain  the  lower 
angle  of  the  wound  in  the  larynx,  is  preferable  to  complete  closure. 

Step  7. — Replace  the  Trendelenburg  by  an  ordinary  tracheotomy  cannula. 

In  Step  5  various  degrees  of  interference  may  be  requisite.  Even  in  cases 
of  rather  extensive  malignant  disease  below  the  vocal  cords  (intrinsic  disease) 
thorough  removal  of  the  growth  and  surrounding  soft  parts  plus  energetic  scrap- 
ing of  the  cartUage  often  gives  good  results.  If  the  growth  invades  the  cartilage, 
then  portions  of  that  structure  must  be  removed.  Sir  F.  Semon  ("Brit.  Med. 
Jour.,"  Oct.  31,  1903)  limits  the  term  partial  laryngectomy  to  cases  where  not 
less  than  one  wing  of  the  thyroid  cartilage,  with,  possibly,  a  part  of  the  cricoid 
and  one  arytenoid,  is  removed.  Removal  of  small  fragments  of  these  car- 
tilages he  includes  under  the  name  "thyrotomy." 

The  lymphatics  of  the  larynx  may  be  considered  as  being  in  two  groups, 
one  above  the  other,  below  the  true  vocal  cords.  The  cords  have  very  scanty 
and  thin  lymphatics  which  drain  into  the  supraglottic  zone  for  the  most  part. 
The  network  of  lymphatics  above  the  vocal  cords  (supraglottic  zone)  is  very 
dense,  easily  injected,  covers  the  epiglottis,  the  aryteno-epiglottic  folds,  the 
superior  or  false  vocal  cords,  and  the  ventricles  of  the  larynx.  The  subglottic 
zone  of  lymphatics  is  not  so  dense  as  that  above.  "Though  the  two  lymphatic 
territories  of  the  larynx  largely  communicate  with  each  other  in  the  posterior 
walls  of  the  larynx,  it  is  rare  to  obtain  a  complete  injection  of  the  endolaryn- 
geal  network  by  puncturing  only  one  of  these  territories.  It  may  be  added 
that  injections  easily  cross  the  middle  line;  but  though  the  mass  injected  into 
one-half  of  the  larynx  easily  passes  into  the  mucous  membrane  of  the  other 
side,  it  is,  on  the  other  hand,  exceptional  for  it  to  pass  as  far  as  the  correspond- 
ing glands  of  that  side."  ("The  Lymphatics,"  Poirier,  Cuneo,  Delamere. 
Leaf's  translation.) 

The  great  importance  of  the  above  anatomical  facts  is  very  evident  and 
they  show  very  clearly  the  reasonableness  of  Semon's  dicta  regarding  the 
conditions  required  for  successful  thyrotomy  for  malignant  disease.  Semon 
gives  the  name  "extrinsic  malignant  disease"  to  that  situated  in  the  supra- 
glottic lymphatic  zone,  and  "intrinsic"  to  that  in  the  subglottic  zone. 

Conditions  Essential  to  the  Success  of  Thyrotomy  for  Malignant 
Disease. — i.  Operation  must  be  restricted  to  early  stages  of  intrinsic  malig- 
nant disease. 

2.  Early  diagnosis  is  indispensable. 

3.  Operation   must   be   thorough.     No   sentimental   considerations   as   to 


200  PHARYNGOTOMY  AND  LARYNGOTOMY. 

the  amount  of  vocal  power  to  be  retained  must  interfere  with  the  removal  of 
sufi&cient  healthy  tissue  from  around  the  neoplasm  in  all  directions. 

4.  Laryngoscopic  examination  rarely  gives  correct  information  as  to 
the  extent  of  the  disease.  If,  on  opening  the  larynx,  the  disease  is  found  to 
invade  the  cartilages,  partial  laryngectomy  must  be  performed,  "or  indeed 
any  other  operation,  the  necessity  of  which  may  become  apparent  when 
the  extent  and  depth  of  infiltration  of  the  new  growth  have  been  definitely 
ascertained." 

Intralaryngeal  operations  are  useless  in  the  face  of  malignancy:  they 
merely  take  away  portions  of  the  growth  and  may  stimulate  it  to  more  rapid 
development.  Even  in  cases  where  there  is  doubt,  but  malignancy  is  strongly 
suspected,  thyrotomy  is  the  proper  operation.  When  the  disease  is  situated 
on  the  posterior  laryngeal  wall  or  when  it  is  too  advanced  for  thyrotomy  or 
partial  laryngectomy  to  be  successful,  then  total  laryngectomy  becomes  a 
necessity.  In  cases  of  extrinsic  malignant  disease  of  the  larynx  subhyoid 
pharyngotomy  gives  the  best  access  for  its  removal. 

LARYNGECTOMY. 

Complete  Laryngectomy. — The  operation  of  laryngectomy  is  called  for 
in  cases  of  malignant  disease  of  the  larynx.  Usually  cases  in  which  the  dis- 
ease has  broken  through  the  bounds  of  the  larynx  and  invaded  neighboring 
tissues  are  considered  inoperable,  but,  as  will  be  seen  in  succeeding  pages, 
such  cases  have  been  successfully  attacked.  The  greatest  danger  of  laryn- 
gectomy is  not  the  immediate  risk  of  the  operation,  but  the  subsequent  aspi- 
ration of  wound  secretions  into  the  lungs,  causing  pneumonia.  This  danger 
is  combated  by  careful  asepsis,  or,  better,  antisepsis,  and  by  using  the  re- 
sources of  plastic  surgery.  After  operation  it  is  wise  to  encourage  the 
patient  to  leave  his  bed  as  early  as  possible. 

The  Operation. — Step  i. — Perform  a  low  tracheotomy  and  insert  a  Tren- 
delenburg cannula  to  prevent  the  entrance  of  blood  into  the  lungs. 

Step  2. — Make  an  incision  in  the  middle  line  from  the  hyoid  bone  to  below 
the  cricoid  cartilage.  This  divides  all  the  soft  parts  down  to,  but  not  through, 
the  cartilages  and  their  connecting  membranes.  If  necessary,  convert  the 
vertical  into  a  T-shaped  incision  by  means  of  a  transverse  cut  near  the  hyoid 
bone. 

Step  3. — (A)  Separate  the  soft  parts  which  are  connected  with  the  laryn- 
geal cartilages,  on  each  side,  from  the  larynx.  Do  this  as  much  as  possible  by 
blunt  dissection;  an  occasional  cut  with  knife  or  scissors  will  be  necessary. 
In  making  this  separation  keep  close  to  the  cartilaginous  walls  of  the  larynx. 
The  larynx  is  now  exposed  anteriorly  and  laterally;  it  is  still  united  to  the 
hyoid  bone  above,  to  the  trachea  below,  and  to  the  oesophagus  behind. 

(B)  If  the  disease  has  infiltrated  surrounding  structures,  then  of  course 
this  step  of  the  operation  must  be  carried  out  by  means  of  dissection  beyond 


LARYNGECTOMY.  20I 

the  disease.  The  operation  becomes,  in  fact,  one  for  the  excision  of  a  tumor 
in  which  the  larynx  happens  to  be  located. 

Step  4. — Stop  all  bleeding.  Divide  the  thyrohyoid  membrane  transversely 
close  to  the  upper  edge  of  the  thyroid  cartilage.  Injure  the  oesophagus  as 
little  as  possible.  Examine  the  epiglottis  carefully.  If  it  is  diseased  or  if  its 
appearance  is  doubtful,  remove  it.  Carefully  separate  the  posterior  wall 
of  the  larynx  from  the  oesophagus,  but  always  bear  in  mind  the  necessity  of 
getting  beyond  the  disease.  The  larynx  is  now  attached  to  the  body  by  the 
trachea  alone.  If  possible,  cut  through  the  cricoid  cartilage  transversely 
and  remove  the  larynx.  If  the  cricoid  is  diseased  or  in  a  suspicious  condition, 
make  the  section  through  the  trachea  at  as  low  a  point  as  may  be  necessary. 

Step  5. — Suture  the  divided  trachea  to  the  skin.  The  trachea  is  liable  to  be 
retracted  dovrawards.  Stop  all  bleeding.  Introduce  an  oesophageal  tube 
into  the  gullet  to  permit  of  feeding.  Pack  the  wound  with  iodoform  gauze. 
Apply  dressings.  Replace  the  Trendelenburg  cannula  by  an  ordinary  trache- 
otomy tube. 

After-treatment. — Give  the  patient  fluid  food  through  the  oesophageal 
tube,  which  is  left  in  situ.  It  is  probably  better  to  omit  the  introduction 
of  the  oesophageal  tube  at  the  time  of  operation,  but  to  pass  the  tube  each 
time  the  patient  requires  nourishment.  The  wound  should  be  frequently 
dressed  and  the  mouth  should  be  kept  clean. 

In  order  to  avoid  confusion  the  author  has  described  the  operation  of 
laryngectomy  as  if  the  removal  of  the  diseased  larynx  constituted  the  whole  of 
the  procedure.  It  would  be  almost  as  logical  to  amputate  the  cancerous  breast 
\vithout  removing  the  fatty  and  lymphatic  contents  of  the  axilla  as  to  remove 
the  larynx  without  attacking  the  cervical  lymphatics  at  the  same  time.  When 
the  larynx  has  been  removed  and  provision  has  been  made  to  retain  control 
of  the  divided  trachea  (Step  5),  it  is  easy  to  gain  access  to  the  cervical  lymph- 
atics and  to  remove  them  in  the  manner  described  for  excision  of  cervical 
tumors  or  by  some  slight  modification  of  that  method. 

Perier's  Operation. — In  extirpating  the  larynx  Perier  discards  the  aid  of  a 
preliminary  tracheotomy. 

Step  I. — Make  a  vertical  median  incision  from  the  hyoid  bone  down  to  a 
point  well  below  the  cricoid  cartilage.  Make  two  horizontal  incisions,  one  at 
each  end  of  the  vertical  cut.     The  wound  is  now  I-shaped. 

Step  2. — Separate  the  soft  parts  from  the  larynx  and  upper  part  of  the 
trachea,  as  has  been  already  described.  With  a  curved  blunt  instrument 
introduced  laterally  separate  the  larynx  and  upper  portion  of  the  trachea 
from  the  oesophagus  (Fig.  287). 

Step  3.— Stop  all  bleeding.  Introduce  a  stout  thread  on  each  side  of  the 
trachea  below  the  line  where  it  is  to  be  divided.  These  threads  are  for  pur- 
poses of  traction.  Rapidly  divide  the  trachea  immediately  below  the  cricoid 
cartilage  and  pull  the  stump  upwards  and  forwards  by  means  of  the  traction 
threads  (Fig  288).     Introduce  into  the  trachea  a  large  curved  cannula  provided 


202  PHARYNGOTOMY  AND  LARYNGOTOMY. 

with  lugs  through  which  the  traction  threads  may  be  passed  and  fastened.  The 
ends  of  the  threads  are  left  long.  The  threads  prevent  the  cannula  changing 
its  position  and  can  still  be  used  for  traction  purposes.  The  anaesthesia  is 
continued  through  the  cannula. 

Step  4. — Complete  the  extirpation  of  the  larynx.  Close  the  wound  with 
sutures  after  providing  for  drainage. 

Step  5. — Suture  the  tracheal  opening  to  the  lowest  angle  of  the  wound 
(Fig.  289). 

Th.  Gluck  brings  the  tracheal  stump  out  through  a  special  buttonhole 
in  the  skin  near  the  sternal  notch,  thus  isolating  it  from  the  laryngectomy 
wound. 


Fig.  287.  Fig. 

Figs.  287  .and  288. — -{Manod  and  Vanverts.) 

Keen's  Method. — In  i8g8  Keen  described  a  method  of  operating,  the  details 
of  which  lead  towards  safety.  For  several  days  prior  to  operation  brush  the 
teeth  thoroughly  and  spray  the  nose  and  fauces  with  a  mild  antiseptic  every 
two  hours,  when  the  patient  is  awake. 

Step  I. — Give  chloroform.  Median  incision  from  above  the  hyoid  bone 
nearly  to  the  sternum.  Expose  the  thyrohyoid  membrane,  larynx,  and  two 
or  more  tracheal  rings.     Divide  the  isthmus  of  the  thyroid. 

Step  2. — Separate  the  structures  to  be  removed  from  their  lateral  connec- 
tions.    Attend   to  hemostasis. 

Step  3. — Put  patient  in  Trendelenburg's  position.  Divide  the  trachea 
transversely  well  below  the  disease  and  below  the  area  of  the  beard  in  men 
(lest  hair  grow  into  the  trachea).  With  three  sutures  fix  the  upper  end  of  the 
trachea  to  the  skin.  Introduce  an  ordinary  tracheotomy  tube  1/2  inch  in 
diameter.  Secure  the  tube  with  sterile  tapes  passed  around  the  neck.  Con- 
tinue the  anaesthetic  through  a  sterile  rubber  tube  passed  into  the  cannula 
and  provided  with  a  funnel. 

Step  4. — Pull  the  upper  end  of  the  trachea  forwards,  and  by  blunt  or  sharp 
dissection  separate  it  from  the  oesophagus.     Close  any  accidental   wounds 


LARYNGECTOMY.  203 

of  the  oesophagus  at  once  with  Lembert  sutures.  Remove  the  disease  and 
the  lar}'nx. 

Step  5. — Pull  the  epiglottis  into  the  wound  and  remove  it. 

Step  6. — Suture  the  anterior  wall  of  the  oesophagus  to  the  tissues  just  below 
the  hyoid  bone.  This  must  be  done  thoroughly  to  prevent  leakage  from  the 
mouth  into  the  wound. 

Step  7. — Remove  the  tracheotomy  cannula  and  close  the  external  wound. 
Provide  drainage  for  twenty-four  hours.  Apply  dressings  above  and  below 
the  tracheal  opening,  which  is  protected  by  any  framework — e.  g.,  a  piU-box 
without  top  or  bottom — covered  with  gauze  to  filter  the  air. 

After-treatment. — Put  to  bed  without     bolster  or  pillow.     Raise  the  foot 
of  the  bed  on  a  chair.     Get  the  patient  up  as  soon  as  possible  (about  the  third 
day).     For  one  or  two  days  feed  by  enemata.     By     1 
the  third  day  the  patient  can  swallow. 

Foderl  has  paid  great  attention  to  means  of 
avoiding  postoperative  pneumonia  due  to  the  aspira- 
tion into  the  lungs  of  secretions  from  the  open 
wound  generally  left  after  laryngectomy.  The 
method  of  operating  adopted  by  him  is  based  on 
experience  gained  in  a  case  of  tracheal  stenosis. 
In  this  case  he  resected  the  affected  portion  of  the 
trachea  and  restored  continuity  by  means  of  a  cir- 
cular suture  of  the  windpipe.  The  result  was  per- 
fect. After  the  trachea  has  been  divided,  and  I 
provided  it  is  not  abnormally  adherent  to  its  sur- 
roundings, it  is  very  easily  pulled  up.  On  the  ^"'-  "^a^"^""^  """^ 
cadaver  is  has  been  shown  that  the  lar}'nx  may  be 

completely  excised,  the  hyoid  bone  united  by  sutures  to  the  first  ring  of  the 
trachea,  the  head  thrown  into  a  position  of  overextension,  and  that  the  sutures 
will  still  hold. 

Foderl's  Operation. — \  preliminary  tracheotomy  is  performed.  The 
larynx  is  removed,  but  the  epiglottis  and  the  ary-epiglottidean  folds  are  pre- 
served if  possible.  Hemostasis  is  carefully  secured  by  means  of  ligatures, 
pressure,  or  torsion.  Unite  the  ends  of  the  ary-epiglottidean  folds  to  the 
posterior  membranous  portion  of  the  trachea,  and  complete  the  continuity 
of  the  posterior  part  of  the  tube.  The  lateral  and  anterior  portions  of  the 
windpipe  are  united  by  catgut  sutures.  The  sutures  are  not  tied  until  all  of 
them  are  in  place.  Two  or  more  of  the  anterior  sutures  surround  the  hyoid 
bone  (submucously),  catch  the  base  of  the  epiglottis,  and  surround  the  first 
tracheal  ring.  After  these  deep  sutures  are  tied,  silk  sutures  are  inserted 
through  the  soft  parts,  and  help  to  relieve  tension  on  the  buried  stitches.  The 
external  wound  is  closed. 

Foderl  remarks  ("Archiv  f.  klin.  Chir.,"  Iviii,  803)  that  after  his  operation 
scarcely  any  more  wound  secretion  enters  the  respiratory  tract  than  does  so 


204  PHARYNGOTOMY  AND  LARYNGOTOMY. 

subsequent  to  any  of  the  endolaryngeal  operations.  A  nearly  linear  circular 
wound  is  left,  the  windpipe  is  cut  oS  from  the  rest  of  the  wound,  and  there 
is  little  danger  of  the  aspiration  of  wound  secretions. 

Foderl  has  operated  on  one  case  in  the  above  manner.  The  patient  was 
out  of  bed  on  the  second  day,  able  to  feed  himself  with  the  oesophageal  tube 
on  the  third  day,  and  went  home  after  two  weeks.  Eight  months  after  opera- 
tion there  was  no  recurrence.  Deglutition  was  good.  Speech  could  be  heard 
at  thirty  feet.  The  patient  still  wore  a  fenestrated  tracheotomy  tube,  but 
he  was  expected  to  give  up  that  before  long. 

The  operation  of  laryngectomy  is  not  absolutely  limited  to  cases  in  which 
the  disease  is  confined  to  the  larynx  itself.  Portions  of  the  oesophagus,  etc., 
may  be  removed  along  with  the  larynx.  Narath  ("Archiv  f.  klin.  Chir.,"  Iv, 
840)  has  published  some  instructive  experiences  on  this  subject.  The  fol- 
lowing description  is  based  on  Narath's  work: 

Combined  Laryngectomy  and  (Esophagectomy. — Step  i. — Perform 
a  low  tracheotomy. 

Step  2. — Extend  the  tracheotomy  wound  upwards  in  the  middle 
line  to  near  the  chin.  Reflect  the  skin  on  either  side  of  the  neck  so 
as  to  expose  the  larynx  and  surrounding  structures.  Isolate  the  diseased 
organs. 

Step  3. — Divide  the  trachea  below  the  disease.  The  inferior  portion  of 
trachea  {i.  e.,  the  portion  leading  to  the  lungs)  is  separated  from  its  surround- 
ings for  a  short  distance  and  its  open  end  brought  into  the  tracheotomy  wound 
in  the  soft  parts;  and  is  there  sutured  after  the  tracheotomy  tube  is  removed. 
In  the  manoeuvre  the  open  end  of  the  trachea  is  so  bent  that  its  opening  faces 
directly  forwards.  There  is  little  danger  of  blood  being  aspirated  into  the 
tracheal  opening  in  its  new  position. 

Step  4. — Remove  the  larynx  and  such  portions  of  the  oesophagus  as  may 
be  diseased,  remembering  to  cut  away  too  much  rather  than  too  little. 

Step  5. — If  comparatively  little  of  the  oesophagus  has  been  removed,  it 
may  be  possible  to  secure  closure  of  its  lumen  by  means  of  suture.  If  a  large 
portion  of  the  anterior  oesophageal  wall  has  been  removed  and  a  small  portion  of 
the  posterior,  it  has  been  possible  to  loosen  the  remnants  of  the  posterior  wall 
from  their  surroundings  sufficiently  to  permit  of  the  upper  and  lower  fragments 
being  brought  together  and  so  to  obtain  a  continuous  posterior  oesophageal 
wall. 

Step  6. — Pack  the  whole  wound  with  iodoform  gauze.  Change  the  dress- 
ings whenever  it  is  desired  to  nourish  the  patient.  Nutriment  is  given  through 
a  stomach-tube. 

As  the  wound  heals  the  cutaneous  edges  become  inverted  and  the  granu- 
lations covered  with  epithelium  until  at  last  the  whole  space  between  the  pos- 
terior oesophageal  wall  and  the  skin  is  covered  by  epithelium.  Thus  a  gutter 
is  formed  leading  from  the  pharynx  to  the  intact  oesophagus  below.  At  the 
lower  end  of  the  gutter  the  tracheal  opening  is  seen  facing  forwards.     The 


LARYNGECTOMY. 


205 


gutter  must  now  be  converted  into  a  tube  by  a  plastic  operation  very  similar 
to  the  operation  for  hypospadias. 

On  each  side  of  the  gutter  A,  B  (Fig.  290)  make  the  skin-flaps  abed  and 
a'  b'  c'  d'.  The  Iiinge  of  the  flap  a  b  c  d  is  along  the  line  a  b;  that  of  flap 
a'  b'  c'  d'  is  along  the  line  a'  b'.  Having  separated  the  above  flaps  from  the  sub- 
jacent tissues,  turn  them  inwards  so  that  the  edge  d  c  of  the  one  flap  meets  and 
is  sutured  to  the  edge  d'  c'  of  the  other  flap.  The  oesophageal  gutter  has  now 
been  converted  into  a  tube  the  anterior  half  of  which  is  lined  by  epidermis. 
The  external  or  raw  surfaces  of  the  two  flaps  (abed  and  a'  b'  c'  d')  now  call 
for  treatment.  Continue  the  horizontal  incision  a,  d  outwards  to  the  point  e; 
the  incision  b  c  to  f;  a'  d'  to  e';  b'  c'  to  f.  Separate  the  flap  e  d  c  f  from 
the  subjacent  tissues,  the  base  of  the  flap  being  the  line  e  f .  Do  the  same  with 
the  flap  e'  d'  c'  f.     Slide  the  two  flaps  towards  each  other  so  that  the  edge  d  c 


Fig.  2QO. 


Fig.  2C)i. 


meets  the  edge  d'  c'  in  the  middle  line.  Suture.  The  sliding  of  these  flaps 
is  rendered  possible  because  the  skin  of  the  neck  is  so  loosely  attached  to  sub- 
jacent structures.  After  healing  has  taken  place,  if  it  is  desired  to  make  use 
of  an  artificial  larynx,  it  will  be  necessary  to  make  an  opening  into  the  pharynx 
at  the  point  A  (Fig.  291).  A  cannula  is  placed  in  the  trachea.  By  means  of 
a  T-joint  on  the  exposed  part  of  the  cannula  a  tube  is  led  upwards  over  the 
skin  through  the  opening  at  A  into  the  pharynx.  In  the  cannula  is  placed  a 
reed.  As  the  patient  expires  air  the  reed  gives  a  musical  note;  the  vibrating 
air  is  carried  into  the  pharynx  through  the  system  of  tubing  described  and  is 
modified  by  the  tongue,  lips,  etc.,  into  speech.  The  speech  is,  of  course,  in 
one  tone,  viz.,  that  of  the  reed. 


CHAPTER  XXIV. 
TRACHEOTOMY. 

Tracheotomy  is  an  exceedingly  simple  operation  under  some  circumstances, 
but  when,  as  is  often  the  case,  one  has  to  dispense  with  the  use  of  an  anaesthetic 
and  operate  on  a  struggling,  choking  child,  on  an  inconvenient  table,  in  a 
badly  lighted  room,  without  proper  assistance,  the  task  of  the  surgeon  is  no 
light  one. 

There  are  two  classical  sites  at  which  the  trachea  may  be  opened — one 
above,  the  other  below,  the  isthmus  of  the  thyroid  gland.  At  the  former  site 
the  trachea  is  much  more  superficial  than  the  latter. 

The  High  Operation. — Place  the  patient  on  his  back  with  the  shoulders 
raised  on  a  pillow,  the  head  extended,  and  in  a  good  light.  If  possible,  ad- 
minister a  general  or  local  anaesthetic.  With  the  finger  locate  the  thyroid  and 
cricoid  cartilages. 

Step  I. — From  a  point  a  little  below  the  middle  of  the  thyroid  cartilage 
make  an  incision,  exactly  in  the  middle  line,  downwards  for  a  distance  of  about 
I  1/2  inches.  Expose  the  deep  fascia,  which  is  attached  to  the  thyroid  car- 
tilage above  and  the  isthmus  below.  Divide  the  fascia  in  the  middle  line. 
By  blunt  dissection  expose  the  trachea,  the  rings  of  which  are  easily  felt  with 
the  finger.  If  there  is  not  enough  space  between  the  cricoid  cartilage  and  the 
isthmus  of  the  thyroid  (which  lies  across  the  third  and  fourth  tracheal  rings), 
make  short  transverse  incisions,  through  the  deep  fascia  where  it  is  attached 
to  the  thyroid  cartilage;  this  permits  one  to  drag  the  isthmus  downwards.  In 
children  preservation  of  the  isthmus  is  of  little  value.  Thomas  Bryant  stated 
long  ago  that  its  division  did  no  harm,  and  the  author,  following  his  advice, 
has,  when  operating  on  children,  paid  no  attention  to  preserving  the  thyroid 
isthmus,  but  has  divided  it  whenever  it  seemed  convenient  to  do  so. 

Step  2. — The  trachea  is  now  bare  to  the  extent  of  three  or  four  rings.  Fasten 
the  trachea  with  a  sharp  hook  a  little  to  one  side  of  the  middle  line.  Let 
an  assistant  hold  the  hook.  Guided  by  the  finger,  introduce  a  knife  slowly 
but  steadily  into  the  trachea  at  the  lower  end  of  the  exposed  area.  Be  careful 
not  to  push  the  knife  in  so  far  as  to  injure  the  posterior  wall  of  the  trachea. 
Cut  upwards  in  the  middle  line  until  three  tracheal  rings  are  divided.  Hold  the 
knife  in  position  in  the  trachea  until,  guided  by  the  knife,  one  can  insert  into 
the  trachea  a  closed  hemostat  or  blunt-pointed  narrow-bladed  scissors.  With- 
draw the  knife.  Open  the  blades  of  the  hemostat  or  scissors  so  as  to  distend 
the  tracheal  wound,  and  slip  a  tracheotomy  tube  into  position.  There  are 
many   manoeuvres   or   dodges  to  facilitate  the  introduction  of  the  cannula; 

206 


TRACHEOTOMY.  207 

the  one  described  has  suited  the  author.  A  few  surgeons  discard  the  cannula 
but  suture  the  edges  of  the  tracheal  wound  to  the  corresponding  edges  of  the 
skin.     One  suture  on  each  side  suffices  to  keep  the  tracheal  opening  patent. 

Transverse  Tracheotomy. —  Otto  Franck  ("Munch,  med.  Woch.,"  1910, 
No.  6)  recommends  the  following  method: 

1.  Transverse  incision  over  the  cricoid.  The  wound  gapes  spontaneously, 
giving  excellent  exposure. 

2.  Division  of  the  linea  mediana  albicans  and  retraction  of  the  muscles 
down  to  the  isthmus. 

3.  Transverse  incision  into  the  trachea  immediately  below  the  cricoid. 
When  the  head  is  extended  the  tracheal  wound  remains  wide  open. 

4.  Introduction  of  tracheotomy  tube  and  suture  of  the  excess  of  skin  wound. 
WTien  the  cannula  is  removed  the  tracheal  wound  closes  of  itself. 

The  Low  Operation. — The  steps  in  the  operation  are  very  similar  to  those 
of  the  high  operation.  The  incision  begins  near  the  circoid  cartilage  and  runs 
downwards  for  two  inches.  After  the  cervical  fascia  is  divided  blunt  dissec- 
tion will  serve  to  expose  the  trachea.  All  veins  which  appear  during  the  dis- 
section must  be  drawn  aside  or  divided  between  ligatures  or  forceps.  The 
index  finger  of  the  left  hand  should  be  frequently  put  into  the  wound  to  feel 
the  position  of  the  trachea  and  to  discover  if  any  abnormal  artery  is  in  the  way. 
The  author  well  remembers  the  glee  with  which  the  late  Sir  John  Struthers 
used  to  exhibit  a  specimen  showing  an  enormous  abnormal  artery  crossing  the 
territory  involved  in  a  low  tracheotomy.  If  the  isthmus  of  the  thyroid  appears, 
it  should  be  pulled  upwards.  The  trachea  is  opened  in  exactly  the  same  man- 
ner as  is  done  in  the  high  operation. 

The  low  operation  is  not  suitable  in  children,  as  in  them  the  trachea  is 
very  deeply  situated,  their  necks  are  short,  and  the  thymus  gland  gets  in  the 
way.     For  adults  and  adolescents  the  low  operation  is  suitable. 

When  the  operation  is  performed  in  cases  of  obstruction  from  external 
pressure,  e.  g.,  in  cases  of  goitre,  and  some  obstruction  exists  below  the  trache- 
otomy opening,  a  tube  should  be  passed  down  the  trachea  beyond  the  obstruc- 
tion. In  emergency,  one  may  use  a  gum-elastic  catheter  for  this  purpose, 
passing  it  through  the  tracheotomy  cannula.  Konig  has  devised  a  special 
metal  cannula  with  a  long  pliable  tube  which  is  occasionally  of  service  (Fig. 
292).  When  a  tracheotomy  tube  has  to  be  worn  for  a  long  time,  one  made  of 
hard  rubber  is  less  irritating  and  more  durable  than  the  usual  metal  instru- 
ment. Fenestrated  tubes  permit  the  patient  to  breathe  through  the  natural 
passages,  and  are  useful  to  test  whether  it  is  safe  to  discard  the  cannula  or  not. 

Trendelenburg's  cannula  (Figs.  293  and  294)  has  rubber  so  arranged 
round  the  intratracheal  part  of  the  tube  that  it  can  be  inflated  and  fill  up  the 
space  between  the  trachea  and  the  tube,  thus  preventing  the  entrance  of  blood, 
etc.,  into  the  lungs.  This  cannula  is  of  great  service  during  certain  operations 
on  the  upper  air  passages,  as  through  it  anaesthetics  may  be  administered. 

Instead  of  surrounding  the  tube  with  an  inflatable  rubber  bag,  some  sur- 


208 


TRACHEOTOMY. 


geons  prefer  to  cover  the  tube  with  compressed  sponge,  which  when  moistened 
swells  in  situ  and  serves  the  same  purpose.  (Hahn's  cannula,  Fig.  295.) 
When  a  tracheotomy  cannula  is  in  position,  it  must  be  retained  by  means  of  a 
tape  passed  round  the  neck  and  secured  to  the  eye-holes  provided  in  the  instru- 
ment.    The  inner  tube  should  be  frequently  removed  and  cleaned.     During 


Fig.  292. — -Konig's  Cannula.  FiG.  293. — Trendelenburg's  Cannula. 

Figs.  292  and  293. — [Esmarch  and  Kowalzig.) 

the  first  few  days  after  operation  the  outer  tube  should  never  be  removed 
except  by  the  surgeon.  Patient  or  nurse  should  never  be  permitted  to  remove 
the  outer  tube  until  the  surgeon  has  satisfied  himself  by  observation  that  they 
are  capable  of  replacing  it. 

Tracheotomy  is  occasionally  performed  as  a  preliminary  to  such  opera- 
tions as  excision  of  the  larynx,   Kocher's  excision  of  the  tongue,  etc.     Pre- 


FiG.  294. — -Trendelenburg's  Cannula  in-situ.  Fig.  295. — Hahn's  Cannula. 

Figs.  294  and  295. — {Esmarch  and  Kowalzig.) 

liminary  tracheotomy  is  either  mediate  or  immediate.  When  the  "mediate" 
operation  is  chosen,  it  should  be  performed  two  or  three  weeks  before  the  major 
operation  to  which  it  is  preliminary. 

The   advantages  claimed  for  mediate  tracheotomy  are:     (i)  The  patient 
has  free  respiration  for  a  period  of  weeks  and  so  may  gain  strength.     (2)  The 


TRACHEOTOMY.  209 

patient  becomes  accustomed  to  respiring  air  which  has  not  passed  through 
the  nose  and  mouth.  (3)  The  tracheal  wound  becomes  fixed  to  the  soft  parts, 
thus  anchoring  the  windpipe  and  preventing  retraction  after  the  larynx,  for 
example,  has  been  excised.  (4)  The  tracheotomy  having  been  done  before 
hand,  the  duration  of  the  major  operation  is  shortened  thereby. 

Advocates  of  the  immediate  operation  claim:  (i)  That  the  time  con- 
sumed in  performing  tracheotomy  is  not  sufficient  seriously  to  influence  the 
success  of  the  major  operation;  (2)  that  it  is  unnecessary  to  accustom  the 
patient  beforehand  to  breathing  through  a  cannula;  (3)  that  while  the  patient 
is  breathing  through  the  cannula  discharges  from  the  cancerous  tongue  or 
larynx  are  liable  to  gravitate  down  the  trachea,  past  the  cannula  into  the  lungs, 
and  cause  pneumonia,  while  the  resisting  power  of  the  lungs  is  lowered  from 
receiving  air  directly  through  the  tracheotomy  tube;  (4)  that  if  any  attempt  is 
to  be  made  to  restore  the  continuity  of  the  windpipe  after  laryngectomy,  the 
adhesions  formed  around  the  tracheotomy  wound  will  prevent  the  necessary 
elevation  or  pulling  up  of  the  lower  trachea. 

In  the  opinion  of  the  author  the  disadvantages  of  mediate  tracheotomy  are 
greater  than  the  advantages,  and  the  immediate  operation  is  preferable,  except 
when  it  is  preliminary  to  excision  of  the  tongue. 


14 


CHAPTER  XXV. 
FOREIGN  BODIES  IN  TRACHEA  OR  BRONCHUS. 

Sometimes  foreign  bodies  may  be  expelled  from  the  trachea  by  inverting 
the  patient,  but,  as  a  rule,  the  body  impinging  against  the  larynx  will  set  up. 
such  spasm  as  to  render  its  expulsion  impossible.  Lejars  is  most  vigorous  in 
his  denunciation  of  the  method.  Tracheoscopy  or  tracheo-bronchoscopy 
(Killian),  whether  the  tube  be  introduced  through  the  mouth  or  through  a 
tracheotomy  wound,  has  frequently  permitted  the  extraction  of  foreign  bodies. 
This  is  a  most  valuable  procedure,  but  unfortunately  requires  an  elaborate 
and  costly  instrumentarium  as  well  as  a  technical  dexterity  possessed  by  but 
few.  By  far  the  most  available  treatment  is  the  high  tracheotomy.  A  gen- 
eral anaesthetic  is  desirable.  Do  not  place  the  patient  in  the  dependent  posi- 
tion until  the  trachea  is  opened.  After  opening  the  trachea  and  retracting 
the  edges  of  the  tracheal  wound  with  retractors  or  stitches,  the  foreign  body 
will  often  pop  out,  or  may  be  lifted  out  with  forceps  or  a  scoop.  If  the  foreign 
body  does  not  promptly  appear  opposite  the  wound,  investigate  the  lower  sur- 
face of  the  glottis;  if  the  body  happens  to  be  there,  remove  it.  Lowering  the 
patient's  head  and  shoulders,  after  opening  the  trachea,  is  often  helpful. 
Touching  the  mucosa  of  the  trachea  excites  coughing  and  so  may  force  the 
foreign  body  into  view.  Coughing  and  inversion  of  the  patient  may  bring  a 
non-impacted  body  from  the  bronchus  into  the  wound. 

If  the  above  measures  are  successful  the  author  inserts  a  linen  or  silk 
suture  in  the  trachea  on  each  side  of  the  wound  and  leaves  these  long  to  serve 
as  tractors  by  means  of  which  the  nurse  may  easily  open  the  trachea  should 
oedema  glottidis  or  such  like  accident  develop.  These  threads  may  be  re- 
moved after  twenty-four  or  forty-eight  hours.  Cover  the  wound  loosely  with 
warm,  moist,  non-ffuffy  gauze.  Instead  of  the  thread  tractors  a  tracheotomy 
cannula  may  be  used.     It  is  not  a  safe  practice  to  close  the  wound  entirely. 

If  the  above  means  fail  to  give  relief  it  is  best  either  to  suture  the  edges  of 
the  tracheal  wound  to  the  skin  or  to  insert  a  large  cannula  and  let  the  patient 
rest.  After  some  hours,  or  next  day,  reopen  the  wound;  if  the  body  is  not 
now  coughed  out,  introduce  a  small  laryngeal  mirror  and  by  the  aid  of  a  strong 
light  investigate  the  trachea.  If  the  body  is  seen  caught  in  the  mucosa,  spray 
with  cocaine  and  endeavor  to  extract  it  with  laryngeal  forceps  or  a  wire  loop. 
This  may  require  several  sittings  before  success  is  attained. 

When  a  foreign  body  is  impacted  in  a  bronchus  and  the  above  measures 
fail  to  give  relief,  one  may  either  attempt  its  extraction  by  means  of  posterior 
bronchotomy  or  await  the  formation  of  a  pulmonary  abscess  which  may  be. 

2IO 


BRONCHOTOMY. 


211 


opened  and  drained.  Unfortunately,  posterior  bronchotomy  is  a  formidable 
operation  and  if  the  Fabian  policy  is  adopted  the  patient  may  die  before  or  after 
solidification  of  the  lung,  and  pneumotomy  under  the  most  favorable  circum- 
stances is  no  triviality. 

POSTERIOR  BRONCHOTOMY.     (SCHWARTZ'S  OPERATION.) 

Anatomy. — The  bronchi  may  be  reached  through  the  posterior  medias- 
tinum, and  as  this  region  is  full  of  vitally  important  structures  it  is  necessary 
to  review  its  anatomy  in  a  practical  manner.  If  one  excises  the  third  to  the 
ninth  dorsal  vertebrae  inclusive,  the  posterior  mediastinum  will  be  sufficiently 
exposed  for  study.      The  most  superficial    (posterior)    structures  which   pre- 


Thyroid 
Com.  car.  A. 


Sup.  lar.  n. 


Vagus 

Int.  jug.  V. 
Trachea 

Inf.  thyroid  a. 
Reccurent  lar.  n. 
Subclav.  art 


Aorta 
Left  plum.  art. 


Left  bronchus 
Thoracic  duct 


Subclav.  V. 


Fig.  2y6. — {Poirier  and  Cha-py.) 


sent  are  vascular,  viz.,  to  the  left  the  aorta,  to  the  right  the  azygos  vein.  At 
the  lower  part  of  the  exposed  area  these  vessels  lie  alongside  each  other 
and  hide  all  subjacent  structures.  As  these  vessels  ascend  they  separate,  the 
aorta  going  to  the  left  where  at  the  level  of  the  fourth  dorsal  vertebra  it  passes 
forwards  (as  the  aortic  arch)  into  the  anterior  mediastinum;  the  azygos  vein 
ascends  towards  the  right  until  it  bends  forwards  at  the  level  of  the  fourth  dorsal 
■  vertebra  to  enter  the  anterior  mediastinum.     The  aorta  and  azygos  thus  form  a 


212 


FOREIGN  BODIES  IN  TRACHEA  OR  BRONCHUS. 


triangle  with  base  above,  and  the  floor  of  which  is  formed  by  the  oesophagus. 
The  apex  (lower  end)  of  the  triangle  in  about  two  inches  below  the  bifurcation 
of  the  trachea.  The  thoracic  duct  follows  the  inner  side  of  the  aorta  and  later 
the  subclavian  artery.  The  right  and  left  pleurae  approach  each  other  between 
the  aorta  and  azygos  behind,  and  the  oesophagus  in  front.  The  right  pleura 
passes  behind  the  oesophagus  in  front  of  the  azygos  so  as  to  form  a  sort  of 
cul-de-sac  (Quenu).  The  two  pleurae  are  loosely  connected  by  areolar  tissue. 
The  position  of  the  pneumogastric  nerves  is  well  seen  in  Fig.  296.  To  expose 
the  oesophagus  it  is  necessary  to  retract  the  pleurae  and  with  them  the  pneu- 
mogastric nerves.  Retraction  of  the  pleurae  and  of  the  oesophagus  exposes 
the  trachea  and  primary  bronchi. 

I.  RIGHT  BRONCHOTOMY. 

The  Operation. — Place  the  patient  in  the  latero-ventral  position  on  the 
edge  of  the  table  with  the  right  arm  hanging  over  the  table  (Fig.  297). 

Step  I. — From  a  point  (A)  at  the  junction  o  the  spine  and  median  border 
of  the  scapula  make  an  incision  to  a  point  (B)  about  i  1/2  inches  to  the  right 
of  the  spines  of  the  vertebrae.  From  the  point  B,  cut  downwards  parallel  to 
the  spinous  processes  for  a  distance  of  about  five  inches   (C).     Make  the 


Fig.  297. — -{Schwartz.) 


{Schwartz.) 


incision  C,  D  which  passes  just  below  the  angle  of  the  scapula.  The  result 
is  the  flap  A,  B,  C,  D.  Reflect  the  flap  A,  B,  C,  D  outwards  so  as  to  expose 
the  fifth,  sixth,  seventh  and  eighth  ribs;  the  flap  consists  of  all  the  soft  parts 
down  to  the  ribs.  J.  D.  Bryant  makes  the  flap  with  its  pedicle  towards  the 
spine. 

Step  2. — Subperiosteally  divide  the  spinal  ends  of  the  exposed  ribs  just 
external  to  the  transverse  processes  (about  i  1/2  inches  from  the  mid-line  of 
the  back).  In  the  same  way  divide  the  ribs  as  far  outwards  as  possible.  Care- 
fully raise  the  lower  and  inner  angle  of  the  flap,  consisting  of  ribs  and  inter- 
costal muscles,  and  separate  it  from  the  subjacent  structures.  Divide  the 
intercostal  muscles  along  the  posterior  or  spinal  line  on  which  the  ribs  were 


BRONCHOTOMY. 


21 


divided,  carefully  exposing  and  tying  the  intercostal  vessels.  Divide  the  inter- 
costal muscles  parallel  to  and  below  the  lowest  rib  to  be  mobilized.  Divide 
the  intercostal  muscles  parallel  to  and  above  the  highest  rib  to  be  mobilized. 
Carefully  separate  the  parietal  pleura  from  flap  of  ribs  and  intercostal  muscles; 
in  doing  this,  gauze  dissection,  i.  e.,  brushing  away  the  pleura  with  gauze,  will 
be  useful.  Turn  the  flap  outwards;  this  is  possible  because  the  ribs  have  been 
divided  far  out  and  the  periosteum  and  intercostal  structures  act  as  a  hinge 
(Fig.  298). 

Step  3. — Carefully  separate  the  pleura  from  the  remnants  of  the  ribs  at- 
tached to  the  spine  and  from  the  side  of  the  vertebrae.  Push  the  pleura  and  the 
lung  outwards,  away  from  the  mediastinum  (Fig.  299).  As  soon  as  the  side 
of  the  vertebra  is  passed,  the  azygos  vein  may  be  seen  running  vertically 
through  the  wound  and  at  the  upper  end,  arching  forwards  to  reach  the  anterior 


Fig.  299. — {Schwartz.) 


Fig.  300. — (Schwartz.) 


mediastinum  (Fig.  300).  Continue  the  separation  of  the  pleura  under  the 
arch  of  the  azygos  until  the  oesophagus,  lying  on  the  bodies  of  the  vertebrae, 
is  reached.  External  to  the  oesophagus  lies  the  pneumogastric  nerve.  Re- 
tract the  pleura  outwards. 

Step  4. — Introduce  the  finger  deeply  into  the  wound  directly  in  the  concavity 
of  the  arch  of  the  azygos  and  feel  the  hard,  prominent,  posterior  border  of  the 
cartilaginous  rings  of  the  bronchus.  Pick  up  the  membranous  posterior  wall 
of  the  bronchus  with  sharp  hooks  or  forceps,  and  incise  it.  Remove  the 
foreign  body.  The  exposed  bronchus  is  situated  about  2  3/4  inches  from  the 
surface  of  the  ribs  (Gluck). 

Step  5. — Introduce  a  soft  dressed  drain  to  the  wounded  bronchus,  possibly 
fixing  it  to  the  bronchial  wound  by  means  of  a  fine  stitch  of  catgut.  Be  sure 
there  is  no  loose  "fluff"  about  the  gauze  at  the  end  of  the  tube.  The  drain 
must  be  soft  to  prevent  dangerous  pressure  necrosis.  Replace  the  flap  and 
sutures  leaving  or  making  space  for  the  exit  for  the  drain.  If  the  foreign  body 
has  given  rise  to  a  peribronchial  phlegmon,  a  more  liberal  drainage  by  means 
of  loose  packing  of  gauze  may  be  advisable. 


214  .  FOREIGN   BODIES   IN   TRACHEA   OR   BRONCHUS. 

II.  LEFT  BRONCHOTOMY. 

Place  the  patient  in  the  left  latero-ventral  position  with  the  left  arm  hanging 
over  the  edge  of  the  table. 

Steps  I  and  2. — Same  as  in  right  bronchotomy  except  that  the  work  is  done 
on  the  left  side. 

Step  3. — Separate  the  parietal  pleura  from  the  remnants  of  ribs  attached  to 
the  spine.  When  the  side  of  the  vertebrae  is  reached,  the  huge  aorta  is  found 
lying  against  the  side  of  the  spine.  At  the  upper  end  of  the  wound  the  aorta 
passes  towards  (arch  of  aorta)  the  anterior  mediastinum.  Continue  the 
separation  of  the  pleura  under  the  arch  of  the  aorta  to  a  height  of  about  2 
inches.  The  left  pneumogastric  soon  presents.  Stop  the  dissection  and 
pull  the  lung  (covered  by  the  intact  pleura)  outwards  with  a  good  retractor. 
With  the  finger  in  the  depth  of  the  wound  feel  the  posterior  prominent  edges 
of  the  bronchial  cartilages.  The  rest  of  the  operation  is  the  same  as  in  right 
bronchotomy. 

In  cases  of  tracheal  stenosis  threatening  life  and  comfort,  whether  the  steno- 
sis is  from  contraction  or  compression,  the  ideal  treatment  is  to  remove  the 
cause.  [Thyroidectomy,  tracheal  plastic,  etc.].  Where  this  is  impossible 
one  may  perform  tracheotomy  and  introduce  through  the  affected  area  a  long 
cannula  (Konig's  cannula;  lobster  tail  cannula)  but  the  cannula  irritates  the 
air  passages  and  gives  rise  to  so  much  trouble  that  the  cannula  may  require 
to  be  removed.  Under  these  grave  circumstances,  the  patient  being  "between 
the  devil  and  the  deep  sea,"  Th.  Gluck  suggests  posterior  bronchotomy.  In 
one  of  Gluck's  cases  of  pneumectomy  the  patient,  while  convalescent  from  the 
operation  and  original  disease,  was  able  to  breath  easily  and  comfortably 
through  the  thoracic  wound  while  the  nose  and  mouth  were  completely  closed. 
This  suggestion  seems  entirely  reasonable  and  should  be  borne  in  mind.  Pos- 
terior bronchotomy  is,  of  course,  no  operation  for  the  tyro,  but  in  a  few  cases 
the  experienced  surgeon  may  find  it  of  value. 


CHAPTER  XXVI. 

GOITRE;  BRONCHOCELE;  STRUMA. 

It  may  not  be  out  of  place  to  remind  the  reader  that  there  are  several 
varieties  of  goitre;  viz.,  parenchymatous,  where  there  is  uniform  enlargement 
of  the  thyroid  tissues;  adenomatous,  where  the  glandular  tissue  is  in  excess  and 
forms  single  or  multiple  tumors;  cystic,  where  from  degeneration  a  cavity  is 
formed  filled  with  colloid  or  other  fluid  and  often  containing  adenomatous 
masses.  There  is  also  that  form  known  as  "exophthalmic  goitre,"  where  the 
tumor  is  associated  with  notable  general  symptoms.  In  any  of  the  above 
varieties  operation  may  be  required. 

THYROID. 

Experiments  and  clinical  observations  have  so  enriched  our  knowledge, 
still  woefully  scant,  of  the  function  of  the  thyroid  and  the  parathyroid  glands 
that  it  is  imperative  to  preface  any  description  of  the  operations  performed 
for  goiter  by  a  very  few  practical  remarks  on  the  thyroid  and  parathyroids,  on 


S.  h.  S.  t. 


Fig.  301. — C.  Fibrous  or  surgical  capsule.  P.  Parathyroids.  MC.  Connective  tissue 
packing,  or  Mayo's  capsule.  X.  Carotid  packet  of  vessels  and  nerves.  Tr.  Trachea. 
Oes.  (Esophagus.     S.  h.  Sterno-hyoid.     S.  t.  Sterno-thyroid.     S.  m.  Sterno-mastoid. 


hyperthyroidism,  hypothyroidism  and  hypoparathyroidism.  The  thyroid  is 
surrounded  by  a  thin,  firm  membrane  of  fibro-elastic  tissue  which  sends 
processes  between  the  glandular  units  for  their  support  and  which  act  as 
pathways  for  the  blood-vessels  and  lymphatics  of  the  gland.  This  covering 
must  not  be  considered  as  a  capsule  in  a  surgical  sense;  it  is,  surgically,  part 

215 


2i6  goitre;  bronchocele;  struma. 

and  parcel  of  the  gland  itself.  Bands  of  dense  connective  tissue  unite  the 
covering  of  the  thyroid  with  the  trachea  (ligaments  of  the  thyroid).  Fig.  301 
shows  how  the  pretracheal  portion  of  the  deep  cervical  fascia  forms  a  fibrous 
or  surgical  capsule  to  the  thyroid;  it  is  the  structure  referred  to  as  the  fibrous 
capsule  when  the  operation  of  thyroidectomy  is  described.  Any  space  which 
may  exist  between  the  fibrous  capsule  and  the  thyroid  gland  is  filled  with 
loose  connective  tissue.  The  loose  connective  tissue  is  apt  to  be  most 
abundant  behind  the  lateral  lobes  of  the  gland.  This  connective  tissue  under 
the  pressure  of  a  goitrous  enlargement  becomes  condensed  and  is  what  Mayo 
speaks  of  in  his  subcapsular  operation. 

The  parathyroids  are  two  or  more  glandular  bodies  which  exist  on  each 
side  of  the  neck  behind  the  lateral  lobes  of  the  thyroid.  The  bodies  are  ellip- 
tical, "are  6  or  7  mm.  long,  3  or  4  mm.  broad  and  i  1/2  or  2  mm.  thick.  The 
length  may  be  as  much  as  15  mm."  (Piersoll). 

The  parathyroids  lie  between  the  fibrous  capsule  and  the  thyroid,  in  the 
loose  areolar  tissue  there  present;  they  may  be  in  contact  with  the  thyroid  or 
with  the  capsule  or  with  both.  Halsted  writes,  "One  is  likely,  therefore,  to 
encounter  these  little  bodies,  usually  two  on  each  side,  at  any  level  from  the 
superior  to  the  inferior  pole  on  the  postero-internal  surface  of  the  gland,  but 
most  commonly  just  internal  to  the  rounded  postero-extemal  border  and  quite 
regularly  near  the  site  of  the  distribution  of  the  terminal  branches  of  the  inferior 
thyroid  artery.  If  the  thyroid  is  lobulated  in  this  situation,  as  is  quite  com- 
monly the  case,  a  parathyroid  may  be  concealed  in  the  cleft  between  the 
lobules."  The  parathyroids  "are  little  ovoid,  spheroid,  lenticular  or  very  flat 
bodies,  exhibiting  much  variety  in  form  and  size  and  even  in  color.  Externally 
they  often  resemble  fat  very  closely  in  consistence  as  well  as  in  color"  (Halsted). 
The  blood-supply  of  the  parathyroids  has  been  carefully  studied  by  Evans 
(Halsted  and  Evans,  "Annals  of  Surg.,"  xlvi.  No.  4).  The  glands  are  always 
supplied  by  definite  parathyroid  arteries  which  usually  arise  from  the  inferior 
thyroid,  but  frequently  come  from  an  anastomosing  channel  existing  between 
the  inferior  and  superior  thyroid  arteries. 

Few,  if  any,  direct  vascular  connections  exist  between  the  parathyroids 
and  the  connective-tissue  envelope  of  the  thyroid. 

Complete  excision  of  the  thyroid  glands  has  been  followed  by  myxcedema 
and  by  tetany.  These  operations  were  performed  before  the  importance  of 
the  parathyroids  was  known.  Later,  when  the  thyroid  has  been  completely 
removed,  experimentally,  but  the  parathyroids  preserved,  myxoedema  has 
developed,  but  not  tetany.  Hypothyroidism  due  to  degeneration  of  the  thy- 
roid leads  to  cretinism  or  to  myxoedema.  Overactivity  of  the  thyroid  (hyper- 
thyroidism) gives  rise  to  a  complexity  of  symptoms  described  by  Graves  in  1835 
and  by  Basedow  in  1840,  and  known  by  the  names  exophthalmic  goitre,  Graves' 
disease,  Basedow's  disease.  Usually  the  thyroid  is  evidently  enlarged  in  hyper- 
thyroidism, but  sometimes  it  is  apparently  normal  in  size.  The  normal 
appearance  is,  however,  only  apparent;  closer  examination  shows  that  the 


GOITRE.  217 

secreting  epithelium,  instead  of  merely  lining  the  acini,  pushes  in  folds  into  the 
acini,  thus  greatly  increasing  the  secreting  surfaces  without  notably  increasing 
the  size  of  the  gland.  This  is  important  to  remember.  When  the  para- 
thyroid   glands    are    excised    tetany    results    (hypoparathyroidism).     Halsted 


Fig.  302. — Thyroids  axd  Paeatharoids  seex  from  Behin-d. — [Halsted  and  Evans.) 

observed  the  early  symptoms  of  tetany  in  one  patient  and  was  able  to  keep 
the  disease  in  check  by  the  administration  of  the  parathyroids  of  beeves  and 
later  by  Beebe's  parathyroid-nucleoproteid.  In  the  published  statistics  of 
partial  strumectomy  the  death  rate  from  tetany  is  3.5%  (in  Kocher's  clinic 
only  1/2%  (Arnd).     Of  course  there  are  many  cases  of  non-fatal    tetany 


2i8  goitre;  bronchocele;  struma. 

following  partial  strumectomy.  The  reason  why  many  cases  of  tetany  recover 
is  probably  due  to  the  fact  that  the  parathyroids  have  not  been  removed,  but 
that  their  circulation  has  been  interfered  with  and  has,  in  time,  become 
reestablished. 

Indications  for  Strumectomy. — ^Very  many  goitres  are  removed  for  cos- 
metic reasons.  The  position,  size,  and  character  of  the  goitre  may  each  con- 
stitute a  positive  indication  for  operation.  Position  and  size  may  give  rise  to  re- 
spiratory and  circulatory  troubles,  as  well  as  to  interference  with  nerves.  The 
character  of  the  disease  indicates  whether  or  not  internal  treatment  may  be  of 
value.  Soft  colloid  nodules  usually  decrease  and  occasionally  disappear  during 
internal  treatment.  Diffuse  strumata  are  those  most  suitable  to  medication 
with  iodine  administered  externally  and  internally.  Medical  treatment  must 
be  stopped  as  soon  at  it  is  shown  to  be  ineffective,  or  the  slightest  evidence  of 
iodism  or  of  Basedow's  disease  appears  (de  Quervain). 

The  local  use  of  iodine  is  liable  to  cause  adhesions  around  the  goitre  and 
thus  render  operation  more  difi&cult.  Injections  of  iodine  or  such  like  drugs 
are  always  improper. 

Almost  all  forms  of  goitre  are  suitable  for  operation  if  causing  symptoms 
or  deformity  or  increasing  in  size  rapidly.  In  exophthalmic  goitre  (Basedow's, 
Graves'  disease)  the  use  of  iodine  is  more  dangerous  than  in  other  forms. 
Remember  that  Graves'  disease  often  remains  stationary  or  improves  under 
any  or  no  treatment,  hence  operation  is  by  no  means  always  called  for,  but 
remember  also  that,  as  the  disease  progresses,  the  powers  of  resistance  de- 
crease, hence  operation  must  not  be  too  long  delayed. 

The  chief  local  characteristic  of  exophthalmic  goitre  is  the  great  vascularity 
of  the  gland.  The  principle  of  treatment  is  to  remove  degenerated  segments 
and  decrease  the  blood-supply.  Kocher,  since  i8go,  has  done  this  by  multiple 
ligation  of  the  thyroid  arteries  and  partial  excision.  This  work  he  accomplishes 
in  several  sittings.  Most  surgeons  operate  in  these  cases  exactly  as  in  ordinary 
goitre. 

Kummel  operates  either  by  enucleation  or  resection  of  a  portion  of  the  goitre 
or  partial  ligation  of  the  afferent  vessels.  His  statistics  show  70  per  cent, 
recoveries  with  5  per  cent,  mortality. 

Kocher  ("Brit.  Med.  Journ.,"  June  2,  1906),  out  of  one  hundred  and 
forty-nine  cases,  had  nine  deaths;  one  hundred  and  forty  cases  were  kept  under 
observation  long  enough  after  operation  to  permit  of  a  definite  statement  as 
to  results;  of  these  one  hundred  and  thirty-one  were  cured  and  nine  notably 
ameliorated.     He  writes: 

"If  we  ligature  one  artery  we  get  some,  but  only  a  slight  amelioration  of 
the  symptoms.  If  we  ligature  two  arteries  the  effect  will  be  exactly  so  much 
greater  as  more  of  the  function  is  inhibited.  If  we  take  away  one  lobe  of  the 
gland  the  effect  is  still  greater.  If  we  put  a  ligature  on  three  of  the  four  arteries, 
we  may  have  a  very  good  result,  and  still  better  if  we  excise  one  lobe  and  put 
a  ligature  on  the  superior  thyroid  artery  of  the  other  side;  it  will  be  even  more 


LIGATIONS.  219 

complete  when  we  combine  unilateral  excision  wath  the  resection  of  the  upper 
and  lower  half  of  the  other  lateral  lobe.  If  we  have  begun  with  one  or  two 
ligations,  and  have  had  an  unsatisfactory  result,  we  are  sure  to  complete  it  by 
adding  a  third  ligature  or  by  excision  of  one-half  of  the  gland.  In  short,  we 
may  say  that  by  operation  it  is  in  our  hands  to  guarantee  a  more  or  less  com- 
plete result."  These  are  Kocher's  words,  and  the  surgeon  of  Berne  is  not 
given  to  exaggeration. 

In  July,  1 9 10,  Kocher  reported  that  he  had  operated  four  hundred  and 
sixty-nine  times  for  Basedow's  disease  with  a  mortality  of  3.4  per  cent.  In 
the  last  seventy-two  cases  there  was  no  death.  Glycosuria  and  hypertrophy 
of  the  thymus  positively  contraindicate  operation.  To  refuse  operation  during 
the  initial  period  of  the  disease  is  to  lose  the  best  chance  of  success. 

Mayo's  statistics  in  cases  of  exophthalmic  goitre  are  as  follows:  Prior 
to  January  i,  1906,  there  were  fifty  primary  thyroidectomies  with  five  deaths 
(10  per  cent,  operative  mortality). 

From  January  i,  1906  to  July  i,  1910  there  were  459  primary  thyroidecto- 
mies with  sixteen  deaths  (3.4  per  cent,  operative  mortality). 

During  this  latter  period  there  were  267  primary  ligations  with  eleven  deaths 
(4.1  per  cent,  operative  mortality). 

The  reason  for  the  death  rate  being  higher  after  ligation  than  after  thy- 
roidecton-y  is  of  course  that  the  lesser  operation  was  chosen  in  the  more  danger- 
ous cases,  in  fact  in  patients  for  whom  any  severe  operation  was  entirely 
unjustifiable. 

C.  H.  Mayo  suggests  that  some  of  the  good  results  following  ligation  of  the 
thyroid  arteries  or  after  sympathectomy  may  be  due  to  destruction  of  many 
of  the  lymphatics  coming  from  the  thyroid;  this  destruction  of  lymphatics  is 
well  calculated  to  diminish  absorption  of  the  thyroidal  secretions  and  thus  to 
prevent  hyperthyroidism. 

The  fact  that  alarming  symptoms  of  hyperthyroidism  very  commonly 
follow  operations  for  Graves'  disease  have  led  to  many  endeavors  to  obviate 
these  symptoms  and  dangers.  None  of  the  endeavors  have  been  proven 
efifectual  though  some  of  them  may  be  so.  A  good  rule  to  adopt  is  one  based 
on  common  sense,  viz.,  handle  the  goitre  gendy  so  as  to  avoid  expressing  thyroid 
juices  which  may  be  absorbed  and  cause  trouble.  Observance  of  this  rule  may 
do  good  and  cannot  do  harm.  It  probably  does  no  good  as  CrUe  has  gently 
massaged  goitres  in  Graves'  disease  and  has  seen  no  evil  follow.  C.  H.  Mayo 
after  removal  of  goitres  swabbed  the  wound  with  Harrington's  solution  so  as 
to  close  the  lymphatics  and  prevent  absorption.  He  has  come  to  the  conclusion, 
and  other  surgeons  agree  with  him  that  this  procedure  while  it  may  be  harmless, 
is  of  no  particular  value.  Crile  came  to  the  conclusion  that  fear  or  psychic 
shock  was  a  great  factor  of  danger  in  the  highly  strung  subjects  of  exophthalmic 
goitre,  and  to  avoid  this  he  adopted  the  plan  of  "  stealing  "  the  goitres.  The  pa- 
tient was  kept  quietly  in  the  hospital  and  was  daily  given  inhalations  of  aro- 
matics  dropped  on  an  ordinary  ether  mask  held  over  the  face.    Sometimes  a  Uttle 


220  goitre;  bronchocele;  struma. 

ether  was  used.  Then  one  day  ether  was  administered  and  only  when  anaes- 
thesia was  complete  was  the  patient  removed  to  the  operating-room  and  the 
goitre  removed.  This  avoidance  of  fright  seemed  to  give  an  improvement  in 
results.  It  is  well  known  that  any  trauma,  even  a  hypodermic  injection  of 
sterile  water  in  the  leg,  may  cause  serious  symptoms  of  intoxication  in  Graves' 
disease.  Crile  thinks  the  trauma  causes  a  nerve  impulse  to  be  sent  to  the  gland, 
thus  occasioning  an  ejaculation  of  thyroid  juice  and  that  Kocher's  success  in  the 
use  of  local  anaesthesia  depends  on  the  fact  that  the  cocaine  prevents  the  nerve 
impulse  reaching  the  gland.  Believing  the  above,  Crile  gave  a  general  anaes- 
thetic, as  described  above,  to  avoid  psychic  shock  and  then  injected  cocaine  to 
produce  local  anaesthesia  and  thus  shut  off  afferent  nerve  impulses  to  the 
gland.  He  thinks  that  much  of  the  value  of  ligation  of  the  arteries  in  the 
treatment  of  Graves'  disease  is  due  to  the  coincident  impairment  of  nerve  con- 
ductivity, the  nerves  being  injured  by  the  ligatures.  To  the  author  it  seems 
that  the  above  notions  may  be  valuable  but  that  they  contain  some  fallacies. 
Riedel  performs  thyroidectomy  under  local  anaesthesia  using  an  extremely 
weak  solution  of  cocaine  or  eucaine  plus  some  adrenalin.  The  injections  are 
massive — first  under  the  skin  and  then  under  the  deep  fascia  and  fibrous  capsule 
of  the  gland.  A  pint  or  more  of  the  solution  is  used.  This  of  course  obscures 
to  some  extent  anatomic  relationships  but  it  so  distends  the  spaces  in  the  areolar 
tissue  between  the  fibrous  capsule  and  the  true  capsule  of  the  gland  that  it 
practically  separates  the  gland  from  its  surroundings  so  that  it  is  easy  to  find 
and  ligate  the  vessels  and  remove  the  gland.  If  Crile's  ideas  are  correct  regard- 
ing reflex  nerve  impulses  causing  ejaculation  of  thyroid  juice  then  Riedel's 
massive  injections  are  well  calculated  to  cut  off  these  impulses  and  at  the  same 
time  facilitate  the  operation.  Mayo's  rules  for  operation  in  Graves'  disease  are: 
If  the  condition  is  fair,  operate;  if  the  pulse  is  130  to  160,  or  if  it  suddenly 
fluctuates  in  tension  and  rapidity,  if  there  is  anaemia  with  swelling  of  the  feet, 
the  patients  are  placed  upon  belladonna  treatment  for  some  days.  The  more 
severe  types  are  also  given  X-ray  exposures  in  addition,  a  treatment  which  is 
continued  from  two  to  six  weeks. 

Whenever  the  symptoms  are  severe  Mayo  contents  himself  with  ligating 
the  superior  pole  of  the  thyroid  on  one  or  both  sides;  later,  if  necessary  he  re- 
moves part  of  the  gland  when  the  patient  is  in  better  condition. 

Besides  the  two  lateral  lobes  and  isthmus  which  compose  the  thyroid 
gland,  the  remnant  of  the  thyroglossal  duct  running  up  from  the  isthmus  often 
forms  an  extra  lobe,  the  pyramidal  lobe,  and  along  its  course  there  may  be 
developed  irregular  masses  of  glandular  tissue — accessory  thyroids.  The 
frequent  presence  of  these  extra  masses  of  thyroid  is  not  surprising,  the  thyroid 
itself  being  developed  from  the  thyroglossal  duct;  surgically  they  are  of  im- 
portance, as  their  presence  is  calculated  to  confuse  the  operator,  ignorant  of 
their  existence. 

The  thyroid  is  surrounded  by  a  strong  covering  of  fascia — fibrous  capsule. 
When  a  goitre  is  present  in  the  gland  (adenoma  or  cyst),  it  is,  of  course,  sur- 


STRUMECTOMY. 


221 


rounded  by  more  or  less  altered  glandular  tissue — glandular  capsule.  The  word 
capsule,  being  applied  both  to  the  outer  fibrous  covering  and  to  the  glandular 
tissue  inside  which  the  tumor  lies,  leads  to  confusion  when  methods  of  operating 
are  described.  In  the  succeeding  pages  the  outer  or  surgical  capsule  will  be 
called  the  fibrous,  the  inner,  the  glandular  capsule. 

The  arteries  of  the  thyroid  are:  (a)  The  superior  thyroid,  entering  the  upper 
pole  of  the  lateral  lobe;  (b)  the  inferior  thyroid,  entering  the  posterior  surface  of 
the  lower  pole  and  in  close  and,  surgically,  dangerous  relation  to  the  recurrent 
laryngeal  nerve  (Fig.  303) ;  (c)  the  thyroidea  ima,  entering  the  isthmus  from 
below. 


Fig.  303. — -Posterior  \'iew  of 
Trachea,  Etc,,  Showing  Course 
OF  Recurrent  Laryngeal  Nerve. 

{Esmarch  and  Kowalzig.) 


Fig.  304. — Superficial  \'eins  Over 

A  Goitre. — (Esviarch  and 

Kawalzig.) 


The  veins  of  the  thyroid  are  of  very  great  importance;  a  study  of  Kocher's 
schemata  (Figs.  304  and  305)  will  give  a  fair  idea  of  their  location  and  importance. 

Operations  for  the  cure  of  goitre  may  be  divided  into  three  groups:  I. 
Excision;  II.  Intraglandular  enucleation;  III.  Incision  and  evacuation. 

I.  EXCISION. 

Complete  excision  of  the  thyroid  gland  is  an  unjustifiable  operation,  as  it 
is  followed  by  fatal  consequences.  As  in  the  case  of  other  organs,  nature  has 
been  la\dsh  in  her  provision  of  functional  material  in  the  thyroid,  and  it  is  safe 
to  say  that  one-fourth  of  the  gland  is  sufficient  for  the  maintenance  of  health. 


TREATMENT  AFTER  STRUMECTOMY. 

When  drainage  has  been  provided,  sufficient  dressings  must  be  applied  to 
soak  up  any  discharges.     Strips  of  adhesive  plaster  are  useful  in  keeping  the 


222 


goitre;  bronchocele;  struma. 


dressing  from  being  displaced;  without  adhesive  plaster  judiciously  applied  it  is 
extremely  difficult  to  prevent  the  dressings  from  becoming  so  rolled  together  that 
there  is  danger  of  exposure  of  the  wound.  As  early  as  possible  have  the  pa- 
tient sit  up;  when  the  horizontal  posture  is  requisite,  encourage  him  to  lie  on  his 
back  and  on  each  side  alternately  so  as  to  avoid  pulmonary  congestion.  Es- 
pecially after  operation  for  exophthalmic  goitre  it  is  of  great  importance  to 

supply  the  patient  with  plenty  of  liquids.  If 
it  is  impossible  to  administer  sufficient  water 
by  the  mouth  give  it  by  rectal  instillation;  i.  e., 
arrange  an  apparatus  so  that  salt  solution 
trickles  continuously  into  the  rectum.  If  the 
rectum  refuse  to  retain  the  liquid,  resort  to 
hypodermoclysis.  The  drain  may  generally 
be  removed  in  twenty-four  to  forty-eight  hours 
after  operation.  If  there  is  excessive  restless- 
ness morphine  in  efficient  doses  is  the  only 
drug  which  seems  to  be  effective.  Profuse 
perspiration  calls  for  the  administration  of 
atrophine  in  doses  of  i/ 150-1/ loo  gr. 

Crile  and  others  have  found  anatomic 
changes  in  the  brain  resulting  from  thyroid 
intoxication.  Such  patients  appear  to  have 
an  increased  susceptibility  to  thyroid  juice. 
Having  by  operation  cut  off  excessive  supplies 
of  thyroid  juice,  it  becomes  necessary  to  treat  the  patient  still  further  and 
endeavor  to  repair  any  damage  which  the  nervous  system  may  have  sus- 
tained. For  this  purpose  nothing  is  better  than  some  form  of  rest  cure  lasting 
several  months. 


Fig.  305. — {Esmarch  and  Kowalzig.) 
I.  Superior  thyroid  artery  and 
vein.  2.  Superior  thyroid  vein.  3. 
Accessory  inferior  thyroid  vein.  4. 
Inferior  thyroid  vein.  5.  Thyroidea 
ima  veins  (chief  and  accessory.) 


Partial  Excision — Excision  of  One  Lobe. 


Method  A.—Kocher's  Transverse  Incision. — Step.  i. — Over  the  most  promi- 
nent part  of  the  tumor  make  a  slightly  curved  transverse  incision  (concavity 
upwards)  from  the  outer  surface  of  one  sternomastoid  muscle  to  the  corre- 
sponding point  on  the  other.  Make  the  incision  too  long  rather  than  too  short, 
as  thorough  exposure  is  the  key  to  safety.  Divide  the  skin  and  platysma. 
Reflect  the  divided  tissues  upwards  and  downwards;  the  sternohyoid,  sterno- 
thyroid, omohyoid,  and  inner  margin  of  the  sternomastoid  muscles  lie  more  or 
less  exposed.  Find  the  anatomic  middle  line  of  the  neck.  Remember  that 
a  unilateral  goitre  pushes  this  line  towards  the  opposite  side  (Figs.  306  and 
314).  In  the  median  line  divide  the  fascia  uniting  the  right  and  left  muscle 
groups.  Do  this  extensively  both  upwards  and  downwards  under  guidance 
of  the  finger  passed  under  the  fascia.  Pass  the  finger  under  the  muscles 
of  the  diseased  side  immediately  below  the  larynx  and,  if  necessary,  divide 


STRUMECTOMY. 


223 


them  transversely  to  the  extent  necessary  for  tJiorough  exposure  of  the  tumor. 
It  is  well  to  divide  the  muscles  between  clamps  so  as  to  prevent  staining  of 
the  wound  with  blood.  Demonstrate  the  fibrous  capsule  of  the  thyroid  and 
split  it  without  injurying  the  gland  beneath.  Division  of  the  fibrous  capsule 
is  absolutely  essential. 


-^siifi' 


V 


"*'-^. 


(Fig.  .• — -Kocher ;^o6.) 

Step  2. — With  the  finger  separate  the  fibrous  capsule  from  the  anterior  sur- 
face of  the  gland,  at  the  same  time  pulling  the  muscles  and  fibrous  capsule 
outwards  with  blunt  retractors.  The  goitrous  thyroid  now  presents  covered 
by  a  peritoneal -like  membrane  (Fig.  3 15).  Any  veins  (accessory  veins)  passing 
from  the  fibrous  capsule  to  the  gland  must  be  doubly  ligated  and  divided.     Do 


Fig.  307. — {Kocher.) 


the  same  for  the  outer  and  posterior  surfaces  (Figs.  307,  308,  and  309).  Now 
dislocate  the  goitre  and  pull  it  out  of  the  wound.  This  removes  pressure  from 
the  trachea.  If  a  general  anaesthetic  is  being  used,  warn  the  anaesthetist  before 
dislocating  the  gland. 

Step  3. — Systematic  ligation  of  vessels. 


224 


goitre;  bronchocete;  struma. 


(a)  With  Kocher's  director  push  the  fibrous  capsule  inwards  and  outwards 
from  the  upper  pole  of  the  thyroid  until  the  superior  thyroid  artery  and  vein 
are  isolated  like  a  pedicle.     Divide  these  between  ligatures  applied  tightly 

(Fig.  3io)- 

(b)  Vigorously  retract  the  muscles  (sternomastoid,  etc.)  of  the  aflfected  side. 
Firmly  pull  the  goitre  over  towards  the  sound  side  (Fig.  309).     The  inferior 


Fig.  308. — {Kocher.) 

thyroid  artery  lies  on  the  deep  muscles  of  the  neck  and  may  be  felt  as  a  transverse 
or  oblique  pulsating  cord  running  from  the  outer  side,  under  the  carotid  to  the 
thyroid  gland,where  that  structure  is  attached  to  the  trachea.  Isolate  the  artery 
with  great  care  and  precision,  because  close  to  it  is  the  recurrent  laryngeal 
nerve.  Only  apply  one  ligature  to  the  vessel.  Many  surgeons  ligate  each 
branch  of  the  inferior  thyroid  close  to  the  gland  and  so  avoid  the  nerve. 

(c)  At  the  lower  pole  of  the  tumor  on  its  median  side  look  for,  doubly 
ligate,  and  divide  the  thyroidea  ima  artery  and  the  accompanying  veins  (Fig.  312). 


Fig.  309. 

Figs.  309  and  310. — {Kocher. 


Fig.  310. 


Step  4. — Isolate  the  thyroid  isthmus.  Doubly  ligate  and  divide  all  vessels 
visible  on  it.  Catch  the  isthmus  in  strong  forceps  (Fig.  313)  and  crush  it 
forcibly.  Remove  the  crushing  forceps.  Doubly  ligate  the  gutter  crushed  in 
the  isthmus  with  single  or  chain  ligatures  and  divide  it. 

Step  5. — The  gland  now  remains  attached  to  the  trachea  and  cricoid  by  its 
inner  margin.     If  this  portion  of  the  gland  is  healthy,  cut  away  the  gland  in 


STRUMECTOMY. 


225 


such  a  manner  as  to  leave  a  thin  layer  in  situ,  protecting  the  recurrent  laryngeal 
nerve.     Ligate  any  bleeding  vessels. 

Step  6. — Wash  the  wound  with  hot  salt  solution.  Examine  for  any  bleeding 
points.  Return  any  divided  muscles  to  their  normal  place  and  unite  them 
by  sutures.     Provide  for  drainage  especially  in  exophthalmic  cases.     Close 


Fig.  311. — {Kocher.) 


Fig.  312. — {Kocher.) 


the  wound.  Apply  dressings.  The  drainage  must  be  removed  in  twenty- 
four  hours  if  no  fluid  blood  is  escaping. 

Method  B. — Mayors  Operation. — Step  1. — As  in  method  A. 

Step  2. — With  the  fingers  separate  the  fibrous  capsule  from  the  anterior 
surface  of  the  gland  at  the  same  time  pulling  the  muscles  and  fibrous  capsule 


Fig.  313. — (Kocher.) 

outwards  with  blunt  retractors  or  forceps.  Doubly  ligate  and  divide  any 
accessory  veins.  Expose  and  elevate  the  upper  pole  of  the  thyroid;  doubly 
ligate  and  divide  the  superior  thyroid  vessels. 

Step  3. — Elevate  the  lower  pole  of  the  thyroid  and  bring  it  into  the  wound. 
If  necessary  make  an  incision  along  the  outer  posterior  border  of  the  thyroid 


226 


goitre;  bronchocele;  struma. 


so  as  to  divide  any  condensed  areolar  tissue  which  may  be  adherent  to  the 
peritoneal-like  investment  of  the  gland.  This  incision  is  not  always  necessary. 
With  a  piece  of  gauze  wipe  or  brush  all  areolar  tissue  adherent  to  the  posterior 
surface  of  the  gland  from  the  gland  so  that  that  surface  of  the  gland  has  no 
moss  of  areolar  tissue  left  adherent  to  it,  but  presents  a  smooth  peritoneal- 
like  appearance.  If  this  is  done  carefully  and  every  bit  of  areolar  tissue,  which 
may  have  penetrated  into  sulci  on  the  gland  surface,  has  been  brushed  off  and 


Fig.  314. — (Mayo.) 


left  adherent  to  the  librous  capsule,  then  the  parathyroids  must  also  have  been 
brushed  off  and  preserved.  Continue  this  gauze  dissection  or  brushing  to  the 
middle  line.  Ligate  the  inferior  thyroid  artery  close  to  the  tumor  as  the  gauze 
dissection  is  being  carried  out.  This  leaves  the  recurrent  laryngeal  nerve 
behind  and  usually  out  of  sight. 

Steps  4,  5  and  6. — As  in  method  .A.. 

Method  C. — Halsted's  operation  is  the  same  as  Kocher's  or  Mayo's  up  to 
a  certain  point.     The  following  quotation  from  Halsted  gives  the  main  points 


STRUMECTOMY. 


22' 


of  his  method.  "Contrary  to  the  universal  custom,  I  do  not,  as  a  rule,  complete 
at  this  moment  the  full  delivery  of  the  entire  gland,  for  fear  of  soiling,  but 
grasp  very  firmly  between  the  thumb  and  finger  the  superior  pole  and  pull  it 
forwards  and  towards  the  mid-line  far  enough  to  make  the  ultra  ligation  of  the 
superior  thyroid  vessels  perfectly  easy.  Attempts  to  completely  dislocate  the 
entire  gland  or  the  inferior  pole  in  this  manner  at  this  stage  of  the  operation 
may  cause  the  rupture  of  some  delicate  blood-vessels  and  consequent  staining 
of  the  field  containing  the  parathyroid  glandules.     But,  if  judiciously  done 


o-^/a  T     9 


Fig.  315. — {Mayo.) 


in  the  manner  described,  the  superior  pole  may  be  fearlessly  grasped  because 
at  this  horizontal  level  there  are  no  vessels  behind  the  superior  pole  to  be  torn. 
When  the  superior  thyroid  vessels  have  been  safely  passed  by  the  thumb  or 
finger,  one  may  proceed  with  considerable  roughness  and  vidthout  fear  of  hemor- 
rhage to  dislocate  even  the  highest  and  deepest  superior  pole.  This  grasp  of 
the  upper  portion  of  the  lobe,  putting  on  stretch  the  superior  thyroid  vessels, 
must  not  be  relinquished  until  released  by  the  ultradivision  of  the  finest  branches 
distributed  to  the  thyroid  gland  in  the  vicinity  of  the  superior  pole.  The  upper 
end  being  thus  liberated  the  delivery  of  the  entire  lobe  is  continued,  and  without 


228  goitre;  bronchocele;  struma. 

the  tearing  of  the  blood-vessels.  From  this  step  on,  throughout  the  operation,  until 
the  last  vessel  has  been  divided,  the  thyroid  lobe  must  be  firmly  drawn  towards 
the  opposite  side,  alternate  relaxation  and  compression  and  undue  pressure  on  the 
trachea  being  carefully  avoided.  From  above  downwards  and  from  before  back- 
wards the  vessels  as  they  bind  or  as  they  present  must  be  clamped  and  divided 
at  their  point  of  entrance  into  the  gland,  as  far  peripherally  as  possible.  Except 
in  the  case  of  the  larger  branches  it  is  usually  unnecessary  to  clamp  the  distal 
end  of  the  cut  vessel,  hemorrhage  from  the  gland  side  being  prevented  by  the 
pressure  exerted  on  the  thyroid  lobe  by  the  unremitting  traction  towards  the 
opposite  side  of  the  neck.  By  this  method  the  recurrent  laryngeal  nerve, 
usually  seen,  is  little  endangered.  In  the  course  of  the  liberation  of  the  lobe 
the  nerve  may  be  dragged  well  to  the  front  of  the  trachea;  of  the  right  nerve 
this  is  particularly  true.  When  in  the  immediate  neighborhood  of  this  nerve, 
at  what  might  erroneously  be  termed  the  hilus  of  the  thyroid  lobe,  one  plunges 
the  sharp-pointed  clamps  into  the  thyroid  gland,  seizing  the  binding  vessels  after 
they  have  disappeared  from  view  in  its  substance.  When  the  habit  is  well 
acquired,  little  if  any  time  is  lost  by  practising  the  clean,  bloodless  method  of 
operating  for  goitre.  The  operation  can  be  carefully  performed  in  about  the 
time  required  for  its  detailed  description." 

Method  D. — Angular  Incision  (Kocher). — Beginning  on  the  sternomastoid 
muscle  at  the  level  of  the  thyroid  cartilage,  make  an  incision  through  the  skin 
and  platysma,  reaching  the  median  line  and  following  the  direction  of  the 
natural  folds  or  creases  of  the  skin.  Continue  the  incision  downwards  in  the 
middle  line  to  the  notch  of  the  sternum.  Reflect  the  angular  skin-flap  and 
expose  the  sternomastoid,  which  must  be  retracted  outwards.  The  rest  of  the 
operation  is  the  same  as  in  Method  A.  This  method  of  exposure  is  of  much 
value  in  cases  where  the  goitre  extends  far  upwards  or  downwards. 

Method  E. — V.  Mikulicz's  Method  of  Resection. — The  following  description 
is  from  v.  Mikulicz's  article,  quoted  by  Berry  ("Diseases  of  the  Thyroid 
Gland"):  "I  began  the  operation,  intending  to  perform  the  ordinary  one 
of  removal  of  the  left  lobe,  and  hoping  to  be  able  to  leave  the  right  intact. 
In  the  course  of  the  operation,  however,  it  became  evident  that  the  right  lobe 
lay  partly  behind  the  sternum,  and  would,  if  left,  prove  a  source  of  danger  to 
the  patient.  So  instead  of  doing  the  usual  extirpation,  I  resected  this  lobe  in 
the  following  manner:  First  of  all  it  was  isolated  as  far  as  possible  in  the 
usual  way  with  blunt  instruments.  The  smaller  blood-vessels  were  tied  with 
double  catgut  sutures.  I  then  tied  the  superior  thyroid  artery  and  vein  in  the 
ordinary  manner  at  the  summit  of  the  lobe;  also  the  superficial  vessels  passing 
to  the  lower  part  of  the  gland.  I  now,  by  means  of  short  snips  of  the  scissors, 
freed  that  portion  of  the  tumor  which  was  adherent  to  the  front  and  side  of  the 
trachea,  but  took  care  not  to  go  too  far  back,  so  as  not  to  come  into  collision 
with  the  recurrent  laryngeal  nerve.  Eventually  the  whole  tumor  was  attached 
only  to  the  angle  between  the  trachea  and  oesophagus,  where  it  covered  the  re- 
current nerve  and  inferior  thyroid  artery.     This  attached  portion,  the  hilus 


RESECTION    THYROID. 


229 


of  the  gland,  I  treated  like  the  short,  thick  pedicle  of  an  ovarian  tumor.  .  .  . 
While  my  assistant  with  his  fingers  compressed  the  vessels  entering  the  hilus, 
I  split  the  pedicle  lengthwise  with  blunt  scissors  into  several  portions,  seized 
each  of  these  in  a  strong  pair  of  pressure  forceps,  and  placed  catgut  ligatures 
in  each  of  the  clefts  so  formed.  Then  the  goitrous  mass  was  cut  off  with  scissors, 
leaving  a  pedicle  of  5  to  10  mm.  (1/5-2/5  inch)  in  length.  The  forceps 
squeezed  out  nearly  all  the  glandular  tissue,  leaving  in  their  grasp  little  but 
connective  tissue.  The  result  was  that  the  catgut  ligatures  could  easily  and 
safely  be  placed  around  the  separated  portions  of  the  pedicle.  Not  a  drop  of 
blood  came  away  from  the  cut  surfaces;  only  here  and  there  in  the  intervals 
was  a  little  oozing;  this  slight  hemorrhage  was  easily  stopped  by  the  application 
of  a  few  ligatures.     The  remainder  of  the  gland  had  now  shrunk  to  a  lump 


Cricoid. 
DivKied  Isthmus, 


ligature, 
around  Isthmus 

Trachea 


Thi/roidea  ima 
Vein. 


Fig.  316. 


about  as  large  as  a  chestnut  which  lay  in  the  angle  between  the  trachea  and 
oesophagus.  Neither  recurrent  nerve  nor  inferior  thyroid  artery  came  into 
view  on  this  side." 

The  above  operation  has  been  frequently  repeated  and  has  proved  very 
successful.  The  advantages  of  the  procedure  are:  (a)  avoidance  of  the  re- 
current nerve;  (i)  avoidance  of  injury  to  the  parathyroids;  (c)  retention  of 
portions  of  the  lobes  attacked,  and  hence  the  possibility  of  removing  parts  of 
both  lobes. 

Method  F. — -Resection-enucleation  (Kocher). — This  method  is  very  like  that 
of  v.  Mikulicz,  but  avoids  leaving  large  ligated  masses  near  the  location  of 
the  recurrent  nerve.  Kocher  has  noticed  that  when  many  large  pedicles  are 
ligated  near  the  nerve  the  necessary  contraction  of  the  tissues  by  the  ligature 
often  causes  injury  to  it. 

The  Operation. — Step  i. — Expose  the  anterior  surface  of  the  diseased  half 


230  goitre;  bronchocele;  struma. 

of  the  thyroid  as  in  Method  A.  Crush  (with  forceps),  ligate,  and  divide 
the  isthmus  close  to  the  disease. 

Step  2. — Through  the  cut  surface  of  the  isthmus  the  goitrous  nodule  will 
present  (Fig.  316).  Beginning  at  the  isthmus  wound,  with  the  finger  or  Kocher's 
director  penetrate  the  glandular  capsule  down  to  the  disease  and  separate  the 
former  from  the  nodule  along  the  lines  A  B  and  C  D.  Note  that  the  separation 
of  gandular  capsule  from  goitrous  nodule  is  only  along  these  two  lines.  With 
strong  forceps  crush  the  glandular  capsule  along  the  lines  of  separation,  remove 
the  forceps,  apply  ligatures  to  the  crushed  tissue,  and  divide  the  glandular 
capsule. 

Step  3. — (irasp  the  goitrous  nodule  and  overlying  glandular  capsule  and 
separate  this  mass  from  the  posterior  portion  of  the  glandular  capsule  until 
all  that  connects  the  goitrous  mass  to  the  body  is  the  outer  portion  of  the  glandu- 
lar capsule  (B  D,  Fig.  316)  well  external  to  the  line  of  the  recurrent  nerve. 
Crush  this  portion  of  the  capsule;  ligate  and  divide  it. 

By  the  above  procedure  the  diseased  tissues  are  removed,  and  with  them 
the  anterior  portion  of  the  gland.  All  the  posterior  surface  of  the  gland  is 
left,  which  is  advantageous  because  danger  to  the  recurrent  nerve,  and  the 
parathyroids,  is  avoided  and  much  useful  glandular  tissue  is  retained.  Hemor- 
rhage is  less  than  in  enucleation.  Kocher  says  that  this  operation,  while 
very  valuable,  is  of  more  limited  application  than  excision.  It  is  inapplicable 
in  cases  of  diffuse  follicular  colloid  degeneration. 

II.  INTRAGLANDULAR  ENUCLEATION. 

Step  I. — Expose  the  anterior  surface  of  the  diseased  lobe  by  Method  A  or 
D.     (See  "Excision.") 

Step  2. — Note  the  most  prominent  part  of  the  tumor,  and  at  this  point 
freely  incise  the  glandular  capsule.  Before  incising,  clamp  or  doubly  ligate 
any  prominent  vessels.  Be  sure  to  penetrate  to,  but  not  into,  the  tumor. 
It  is  not  always  necessary  to  incise  the  glandular  capsule  as  the  tumor  may 
have  so  grown  as  to  push  aside  all  the  gland  tissue  which  originally  covered  it. 
In  such  a  case  it  is  easy  to  enucleate  the  growth  by  brushing  aside  with  gauze 
all  tissue  adherent  to  it. 

Step  3. — With  blunt  dissection,  using  the  finger,  Kocher's  director,  or 
closed  blunt  scissors,  shell  the  tumor  out  of  its  glandular  capsule.  Sometimes 
this  is  more  easily  accomplished  if  the  fluid  contents  are  drawn  off,  as  in  the 
case  of  a  large  ovarian  cyst.  The  shelling-out  must  be  done  rapidly,  as  bleed- 
ing is  often  abundant.  The  surgeon  must  always  keep  his  instrument  close 
against  the  tumor- wall,  otherwise  the  vascular  glandular  capsule  will  be  injured 
and  more  bleeding  provoked. 

Step  4. — Immediately  on  the  removal  of  the  tumor  temporarily  pack  the 
cavity  with  gauze  and  pull  the  whole  cavity  forwards.  Gradually  remove  the 
gauze,  and  with  forceps,  ligatures,  and  catgut  stitches  stop  hemorrhage.     The 


TRANSPLANTATION    THYROID.  23 1 

hand  placed  behind  the  thyroid  can  press  the  floor  of  the  wound  cavity  forwards 
Avithin  reach  and  control.  Hemostasis  must  be  absolute,  as  primary  union 
is  of  great  importance. 

Step  5. — Provide  for  drainage  for  twenty-four  hours.  A  tubular  drain  is 
best.  Close  the  wound  with  sutures.  For  this  purpose  Berry  uses  three  layers 
of  fine  sutures.  One  layer  obliterates  the  cavity  in  the  gland,  another  unites 
the  muscles,  and  a  third,  the  skin-wound. 

Where  large  multilocular  cysts  are  present  F.  J.  Shepherd  ties  and  divides 
the  superior  thyroid  vessels,  delivers  the  gland  and  enucleates  the  tumor. 
This  leaves  a  thin  layer  of  gland  tissue  behind,  and  there  is  no  danger  of  in- 
juring the  recurrent  nerve.  Occasionally  Shepherd  ties  the  inferior  thyroid 
as  well  as  the  superior.  In  the  light  of  Evans'  researches  into  the  blood  supply 
of  the  parathyroids,  ligation  of  the  inferior  thyroid  artery  becomes  a  matter 
of  much  greater  gravity  than  it  was  formerly  thought  to  be. 

III.  INCISION  AND  EVACUATION;  MARSUPIALIZATION. 

In  certain  cases  of  cystic  goitre  where  repeated  attacks  of  inflammation 
have  caused  the  formation  of  many  adhesions  none  of  the  preceding  methods 
are  applicable,  and  a  simpler  operation  must  be  done. 

Step  I. — Make  an  incision  over  the  most  prominent  portion  of  the  tumor 
and  expose  a  few  inches  of  its  surface. 

Step  2. — Doubly  ligate  the  vessels  of  the  tumor  capsule  (both  fibrous  and 
glandular  capsule)  and  incise  the  tumor.  Stitch  the  edges  of  the  wound  in  the 
cyst- wall  to  the  skin. 

Step  3. — Explore  the  cyst  with  the  finger  and  shell  out  all  degenerated  colloid 
masses.  Stop  bleeding  by  means  of  forceps,  ligatures,  hemostatic  sutures, 
hot  water,  and  packing.     Drain  the  cavity. 

The  great  objection  to  this  procedure  is  the  open  wound  which  is  left,  the 
dangers  of  subsequent  infection,  and  the  possible  persistence  of  a  fistula;  its 
advantages  are  ease  of  accomplishment  and  immediate  safety.  The  opera- 
tion has  a  distinct  though  limited  field  of  usefulness. 

IV.  TRANSPLANTATION  OF  THYROID  OR  PARATHYROID 
GLANDULAR  TISSUE. 

Payr  ("German  Surg.  Congress,"  1906)  has  made  some  remarkable  ex- 
periments on  animals  and  has  endeavored  to  prevent  the  tetany  and  cachexia 
strumipriva  which  follow  complete  thyroidectomy.  In  animals  he  implanted 
fragments  of  thyroid  gland  into  a  pouch  made  in  the  spleen.  Hemorrhage 
ceased  as  soon  as  the  "living  tampon"  was  sutured  in  place.  Omentum  was 
stitched  over  the  splenic  wound.  After  some  days  the  rest  of  the  thyroid  gland 
was  removed  without  ill  resulting.  As  a  control  Payr  in  some  cases  subse- 
quently removed  the  spleen  and  caused  death  from  tetany. 

Encouraged  by  the  above  Payr  operated  on  a  girl  of  six  years,  a  complete 


232  goitre;  bronchocele;  struma. 

idiot  who  had  been  treated  for  three  years  with  thyroid  tablets  unsuccessfully. 
He  removed  a  part  of  the  healthy  thyroid  form  the  patient's  mother  and  im- 
mediately implanted  it  in  the  child's  spleen.  Both  patients  recovered  from  the 
operation.  The  psychic  improvement  in  the  child  was  "incontestable." 
Payr  has  noticed  that  grafts  from  ductless  glands  generally  do  well  in  the  spleen 
while  those  from  excretory  glands  do  not  do  so  well. 

Following  Payr's  lead,  Halsted  has  endeavored  to  transplant  parathyroid 
glands  which  have  been  accidentally  deprived  of  their  vascular  supply  during 
strumectomy. 

In  a  case  of  tetany  following  thyroidectomy  a  cure  resulted  from  the  im- 
plantation of  two  parathyroid  bodies  under  the  skin  of  the  abdomen.  The 
implants  were  obtained  from  two  men  operated  on  for  goitre.  (W.  David- 
son, "Beitr.  z.  klin.  Chir.,"  Ixvi,  Hft.  i.) 


CHAPTER  XXVII. 

THYMUS  GLAND. 

An  enlarged  thymus  gland  may  so  press  upon  the  trachea  as  to  necessitate 
operation.  Operation  may  be  either  exopexy  with  or  without  partial  excision 
or  it  may  be  one  of  complete  excision. 

A.  Exopexy. — Expose  the  upper  part  of  the  thymus  gland  by  a  median 
incision  above  the  sternal  notch.  Pull  the  gland  upwards  and  forwards.  An- 
chor it  with  a  few  stitches  to  the  fascia  over  the  sternum.  In  the  hands  of 
Rehn,  exopexy  gave  a  good  result.  In  a  similar  case  Fritz  Konig  resected  a 
portion  of  the  gland,  anchoring  the  remainder  to  the  sternum,  and  obtained  a 
cure  of  the  dyspnoea. 

B.  Excision  of  the  Enlarged  Thymus.  (Ehrhardt,  "Archivfiirklin.  Chir., 
Ixxviii,  602.) 

Step  I. — Make  a  median  incision  from  a  point  just  below  the  larynx  to  a 
point  about  1/2  inch  below  the  upper  edge  of  the  sternum.  Layer  by  layer 
divide  the  tissues,  including  the  isthmus  of  the  thyroid,  untU  the  trachea  is 
fully  exposed.  At  each  expiration  a  large  part  of  the  thymus  rolls  forward  in 
the  root  of  the  neck. 

Step  2. — Seize  the  thymus  with  forceps  and  pull  it  forwards.  Enucleate 
the  gland  by  blunt  and  sharp  dissection  attending  to  hemostasis  at  the  same 
time.     Partially  tampon  and  close  the  wound. 

Ehrhardt  operated  with  success  as  above  in  one  case. 

Veau  and  Olivier  ("Arch,  de  med.  des.  enfants,"  1910,  Nov.)  operated  in 
three  cases  in  much  the  same  manner  using  chloroform  narcosis.  After 
exposing  the  gland  and  fixing  it  with  forceps  they  penetrated  the  capsule  first 
on  the  left  side  and  enucleated  the  gland,  then  they  did  the  same  on  the  right 
side,  and  closed  the  cavity  with  catgut  sutures.  Veau  and  Olivier  performed 
total  extirpation  as  above  described  without  ill  effect,  but  if  one  fears  removal 
of  the  whole  gland  one  may  content  oneself  with  the  removal  of  one  half. 
("La  Presse  Med.,"  ix,  1910.) 

The  surgeon  must  remember  that  the  thymus  gland  may  cause  death  from 
pressure  without  the  presence  of  any  visible  or  palpable  tumor  in  the  neck. 

Chevalier  Jackson  ("Jour.  Amer.  Med.  Assoc,"  May  25,  1907)  has  demon- 
strated an  enlarged  thymus  by  means  of  the  X-rays,  and  with  the  bronchoscope 
showed  that  pressure  from  the  thymus  produced  scabbard  deformity  of  the 
trachea.  After  tracheotomy  Jackson  measured  the  distance  from  the  trache- 
otomy wound  to  a  point  i  cm.  from  the  bifurcation  of  the  trachea  and  procured 
a  tracheotomy  cannula  of  this  length.  The  use  of  a  cannula  passing  through 
the  constricted  trachea  notably  facilitated  the  removal  of  the  thymus. 

233 


PART  II.— THE  THORAX. 


CHAPTER  XXVni. 
OPERATIONS  ON  THE  BREAST. 

Evacuation  of  Abscess  by  Incision. — The  classical  method  of  incising 
the  breast  to  empty  an  abscess  is  exceedingly  simple.  Make  an  incision  through 
the  skin,  beginning  peripheral  to  the  areola,  along  a  line  radiating  from  the  nipple 
and  situated  over  the  inflammatory  swelling.  By  combined  sharp  and  blunt 
dissection  penetrate  the  abscess,  clean  the  cavity,  and  provide  drainage.  The 
object  of  radial  incision  is  to  avoid  transverse  and  unnecessary  division  of 
glandular  structures. 

To  avoid  deformity  from  scars  it  has  been  suggested  to  use  the  principle  of 
Thomas'  operation  for  adenomata  of  the  breast.  Make  a  curved  incision  along 
the  line  of  junction  of  the  lower  edge  of  the  breast  and  the  chest-wall.  Penetrate 
to,  but  not  through,  the  pectoral  fascia.  Separate  the  breast  from  the  chest- 
wall  until  it  is  possible  to  gain  access  to  the  abscess  from  the  deep  surface  of 
the  gland.  Evacuate  the  pus.  Introduce  one  or  two  drainage-tubes  into 
the  cavity  and  bring  their  ends  out  through  the  wound.  Replace  the  mamma 
on  the  thoracic  wall.     Partially  close  the  skin-wound  by  sutures. 

In  this  operation  the  incision  is  larger  and  the  dissection  is  much  greater 
than  is  required  in  simple  incision,  but  the  drainage  is  excellent  and  the  result- 
ing scar  is  below  the  breast  and  hidden  by  the  natural  fold  existing  there. 

Mastopexy. — Mastoptosis  or  pendulous  breast  is  common,  may  be  due  to 
one  or  several  of  many  causes,  may  be  harmless  except  as  a  disfigurement,  but 
it  may  give  rise  to  chronic,  painful  engorgement  and  to  various  inflammations. 
Ch.  Girard  ('' Archiv  fiir  klin.  Chir.,"  xcii,  829)  describes  the  various  methods 
of  treatment  adopted  for  mastoptosis  and  suggests  an  operation  which  he 
has  successfully  used. 

Step  I. — Reflect  the  breast  upwards,  as  in  the  Thomas'  operation  for 
benign  neoplasms,  until  the  second  costal  cartilage  is  reached. 

Step  2. — Expose  the  second  costal  cartilage  by  incising  the  pectoral  fasc" 
and  bluntly  splitting  the  pectoralis  major  muscle  parallel  to  its  fibres. 

Step  3. — With  a  slightly  curved,  strong  needle  pass  a  very  strong  catgut 
suture  from  below  upwards  through  the  second  costal  cartilage.  Pass  this  suture 
through  the  fibrous  tissue  of  the  upper  pole  of  the  mamma.  Tie  the  suture 
after  tightening  it  sufficiently  to  bring  the  breast  up  into  the  desired  position 
but  still  leaving  the  loop  of  the  suture  somewhat  open  like  a  sling.     Through 

235 


236  OPERATIONS  ON  THE  BREAST. 

the  loop  of  the  first  suture  pass  about  four  catgut  threads  and  stitch  each  of 
these  to  different  parts  of  the  under  surface  of  the  breast.  The  result  of  the 
above  procedures  is  that  a  number  of  radiating  threads  pass  from  the  primary 
suture  in  such  a  manner  that  all  parts  of  the  breast  are  attached  to  the  second 
costal  cartilage  by  a  series  of  slings,  but  the  breast  can  still  be  lifted  up  from 
the  chest  wall. 

Step  4. — From  above  downwards  suture  the  under  surface  of  the  mamma 
to  the  pectoral  fascia. 

Step  5. — Close  the  skin  wound. 

Excision  of  Non-malignant  Neoplasms  of  the  Breast. — I.  When  the 
breast  is  the  seat  of  very  large  or  multiple  non-malignant  neoplasms,  the  whole 
organ  must  be  excised,  but  it  is  not  necessary  to  remove  the  pectoral  fascia  or 
axillary  contents.  Make  an  oblique  elliptical  incision  over  the  breast  and  in- 
cluding the  nipple.  This  incision  runs  from  above  and  outwards,  downwards, 
and  inwards;  it  begins  and  ends  just  beyond  the  confines  of  the  gland.  Through 
the  incision  dissect  the  skin  free  from  the  breast,  by  blunt  and  sharp  dissec- 
tion separate  the  breast  from  the  pectoral  fascia  and  remove  it.  Attend  to 
hemostasis.     Close  the  wound. 

The  operation  is  perhaps  the  easiest  in  surgery.  When  there  is  doubt  as 
to  the  malignancy  or  non-malignancy  of  the  disease  present,  and  histological 
examination  is,  for  any  proper  reason,  not  convenient,  then  the  above  operation 
should  not  be  performed;  the  patient  ought  to  be  given  the  benefit  of  the  doubt 
and  radical  measures  adopted. 

II.  When  the  breast  is  the  seat  of  one  or  perhaps  of  two  or  three  small 
non-malignant  neoplasms,  such  may  be  excised,  leaving  the  gland 'practically 
intact. 

Method  A. — Fix  the  neoplasm  by  grasping  it  between  the  finger  and  thumb. 
Make  an  incision  over  the  tumor,  peripheral  to  the  nipple  areola,  along  a  line 
radiating  from  the  nipple.  Expose  the  tumor  by  this  incision  and  either  shell 
or  dissect  it  out  of  its  bed.  Attend  to  hemostasis.  Close  the  wound,  with  or 
without  drainage. 

Method  B. — Thomas'  operation  has  the  great  advantage  of  avoiding  visible 
scars.     It  has  been  sufficiently  described  on  page  235. 

Excision  of  the  Breast  for  Cancer. — A  few  years  ago  typical  excision  of 
the  breast  could  be  completed  in  a  few  mintues.  The  operation  consisted  in 
making  an  elliptical  incision  over  the  breast,  including  the  nipple,  in  rapidly 
reflecting  the  skin  from  the  gland,  and  in  tearing  and  cutting  the  gland  from 
the  pectoral  fascia.  Through  the  wound  the  finger  was  pushed  up  into  the 
corresponding  axilla,  and  if  any  lymphatic  glands  were  found  enlarged,  such 
were  removed.  The  operation  was  primarily  safe.  The  ultimate  results 
were  such  that  many  experienced  surgeons  claimed  recurrence  always  took 
place.  Disgusted  with  the  want  of  success  attained,  thoughtful  operators 
became  more  radical  and  more  successful.  The  typical  operation  no  longer 
consisted  in  removal  of  the  mamma  and  the  axillary  glands  if  they  were  pal- 


MAMECTOMY.  237 

pably  diseased,  but  the  mamma,  the  pectoral  fascia,  the  axillary  glands,  and 
fat  were  removed  in  one  piece.  The  primary  mortality  of  the  operation  did 
not  increase  perceptibly;  the  ultimate  results  were  infinitely  bettered. 

The  Operation. — The  incision  A,  B,  C  (Fig  317)  is  made  through  the  skin. 
The  ellipse  between  B  and  C  includes  the  nipple  and  any  portions  of  skin  which 
may  be  adherent  to  the  tumor.  The  skin-flap  A  B  C  E  is  reflected  downwards 
well  below  the  limits  of  the  breast  and  to  the  posterior  border  of  the  axilla 
(i.  e.,  to  the  edge  of  the  latissimus  dorsi).  The  skin-flap  A  B  C  D  is  reflected 
upwards  well  above  the  limits  of  the  breast  and  so  as  to  expose  the  anterior 
boundary  of  the  axilla.  Beginning  below  the  breast,  one  dissects  from  the 
pectoralis  major,  the  fat  of  the  chest-wall,  the  pectoral  fascia,  and  with  them 
the  diseased  mamma.  This  is  continued  to  a  point 
well  above  the  breast,  to  the  base  of  the  skin-flap 
A  B  C  D.  There  is  now  a  mass  of  fat,  gland,  and 
pectoral  fascia  unconnected  with  the  chest-wall,  but 
continuous  with  the  fatty  and  lymphatic  axillary 
contents.  The  chest  wound  is  to  be  protected  by 
an  aseptic  pad  or  towel  and  the  surgeon  attacks  the 
axilla.  Beginning  on  the  outer  or  arm  side  of  the 
axilla,  its  fatty  contents  are  dissected  from  the 
vessels  and  nerve-trunks  there  situated.     The  first  p^^ 

efifort  should  be  to  dissect  the   axillary   vein   free 

from  its  fatty  surroundings.  Any  axillary  branches  of  the  vein  should  be 
divided  between  two  fine  ligatures  whenever  found.  When  this  dissection  is 
being  made,  the  arm  should  be  kept  as  close  to  the  body  as  is  consistent 
with  free  access  to  the  axilla;  the  object  attained  by  doing  so  is  that  other- 
wise branches  of  the  axillary  vein  would  be  put  on  the  stretch  and  rendered 
unrecognizable,  and  further  that  in  this  position  it  is  possible  to  retract  the 
pectoralis  major  upwards,  thus  giving  access  to  the  apex  to  the  axilla. 

The  contents  of  the  axilla  are  easily  separated  from  the  posterior  and  internal 
walls  of  the  space.  If  it  is  convenient  to  save  the  small  nerves  crossing  the 
axilla,  they  may  be  preserved;  but  if,  as  is  usually  the  case,  time  would  be  lost 
in  so  doing,  they  should  be  sacrificed.  The  only  connection  left  between  the 
mass  to  be  removed  and  the  body  is  at  the  apex  of  the  axilla.  If  the  lymphatics 
higher  up  are  believed  to  be  healthy,  this  connection  is  divided  and  the  excision 
is  complete.  If,  on  the  other  hand,  it  is  suspected  that  the  disease  extends 
further,  then  the  pectoralis  major  is  divided  and  access  is  gained  to  the  chain 
of  lymphatics  running  up  under  the  clavicle.  These  are  removed  in  one  piece 
with  the  tumor  mass.  The  wound  in  the  muscle  is  sutured.  The  whole  wound 
is  closed,  axillary  drainage  being  provided. 

When  the  pectoral  fascia  is  being  removed  from  the  pectoralis  major, 
should  any  disease  be  found  or  suspected  to  exist  in  that  muscle  the  whole 
muscle  must  be  excised  in  one  piece  with  the  mamma. 

The  operation,  as  described,  is  not  one  for  a  novice,  but  in  the  hands  of  an 


238  OPERATIONS  ON  THE  BREAST. 

experienced  surgeon  it  is  safe  and  has  given  results  which,  when  compared  to 
those  previously  obtained,  might  almost  be  described  as  brilliant.  Halsted  has 
still  further  elaborated  the  operation,  making  it  tremendously  extensive  and 
most  remarkably  successful.  His  success  is  so  great  that  the  author  considers 
the  Halsted  operation  or  some  modification  thereof  to  be  the  preferable  treat- 
ment for  operable  mammary  cancer. 

Halsted  Operation. — (The  following  description  is  compiled  from  Halsted's 
articles  in  the  "Annals  of  Surgery,"  vol.  xx,  No.  5,  and  xxviii,  No.  5.) 

Principle  oj  Operation. — The  pectoralis  major  muscle,  entire  or  all  except  its 
clavicular  portion,  should  be  excised  in  every  case  of  cancer  of  the  breast, 

because  the  operator  is  enabled  thereby  to  remove 
in  one  piece  all  the  suspected  tissues.  The  sus- 
pected tissues  should  be  removed  in  one  piece. 

Step  I. — The  skin-incision  is  carried  at  once 
and  everywhere  through  the  fat  (Fig.  318). 

Step  2. — The  triangular  flap  of  skin  A  B  C  is 
reflected  back  to  its  base  line,  C  A.  There  is  noth- 
ing but  skin  in  this  flap.  The  fat  which  lined  it  is 
dissected  back  to  the  lower  edge  of  the  pectoralis 
major  muscle,  where  it  is  continuous  with  ithe  fat 
of  the  axilla. 

Fig.  318.  Step  3. — The  costal  insertions  of  the  pectoralis 

major  are  severed  and  the  splitting  of  the  muscle, 
usually  between  its  clavicular  and  costal  portions,  is  begun,  and  continued  to 
a  point  about  opposite  the  scalenus  tubercle  on  the  first  rib. 

Step  4. — At  this  point  the  clavicular  portion  of  the  pectoralis  major  and 
the  skin  overlying  it  are  cut  through  hard  up  to  the  clavicle.  This  cut  exposes 
the  apex  of  the  axilla. 

Step  5. — The  loose  tissue  under  the  clavicular  portion  of  the  pectoralis 
major  is  carefully  dissected  from  this  muscle  as  the  latter  is  drawn  upwards 
by  a  broad  sharp  retractor.  This  tissue  is  rich  in  lymphatics  and  is  sometimes 
infected  with  cancer. 

Step  6. — The  splitting  of  the  muscle  is  continued  out  to  the  humerus,  and 
the  part  of  the  muscle  to  be  removed  is  now  cut  through  close  to  its  humeral 
attachment. 

Step  7. — The  whole  mass,  skin,  breast,  areolar  tissue,  and  fat,  circumscribed- 
by  the  original  skin  incision,  is  raised  up  with  some  force,  to  put  the  submuscular 
fascia  on  the  stretch  as  it  is  stripped  from  the  thorax  close  to  the  ribs  and  pec- 
toralis minor  muscle.  It  is  well  to  include  the  delicate  sheath  of  the  minor 
muscle  when  this  is  practicable.  This  step  has  been  modified  by  Halsted  in  that 
he  now  ("Annals  of  Surgery,"  Nov.,  1898)  removes  the  pectoralis  minor  and 
exposes  the  subclavian  vein  at  its  inner  part. 

Step  8. — The  axilla  is  now  stripped  of  its  contents  and  its  anterior  wall  at  one 
time,  from  within  outwards  and  from  above  downwards.     The  axillary  con- 


HALSTED  S    OPERATION. 


239 


tents  are  dissected  away  with  scrupulous  care  and  with  the  sharpest  possible 
knife.  The  axillary  vein  should  be  stripped  absolutely  clean.  Not  a  particle 
of  extraneous  tissue  should  be  included  in  the  ligatures  which  are  applied  to 
the  branches,  sometimes  very  minute,  of  the  axillary  vessels.  In  liberating 
the  vein  from  the  tissue  to  be  removed  it  is  better  to  push  the  vein  away  from 
the  tissues  rather  than,  holding  the  vein,  to  push  the  tissue  away  from  it.  It 
may  not  be  necessary,  but  it  is  well  to  expose  the  artery  and  remove  the  possibly 
infected  tissue  above  it.  It  is  best  to  err  on  the  safe  side  and  remove  in  all  cases 
the  loose  tissue  above  the  vessels  and  about  the  axillary  plexus  of  nerves. 


Fig.  319. 


Fig.  320. — {Kocher.) 


Step  9. — ^Having  cleaned  the  vessels,  we  may  proceed  more  rapidly  to  strip 
the  axillary  contents  from  the  inner  wall  of  the  axilla — the  lateral  wall  of  the 
thorax. 

Step  10. — When  we  have  reached  the  junction  of  the  posterior  and  lateral 
walls  of  the  axilla,  or  a  little  sooner,  an  assistant  takes  hold  of  the  triangular 
flap  of  skin  and  draws  it  outwards,  to  assist  in  spreading  out  the  tissues  which 
lie  on  the  subscapularis,  teres  major,  and  latissimus  dorsi  muscles.  The  operator 
cleans  the  posterior  wall  of  the  axilla  from  within  outwards.  The  subscapular 
vessels  are  exposed  and  caught  before  being  divided.  The  subscapular  nerves 
may  or  may  not  be  removed. 

Step  II. — Having  passed  these  nerves,  the  operator  has  only  to  turn  the  mass 
back  into  its  normal  position  and  to  sever  its  connection  with  the  body  of  the 
patient  by  a  stroke  of  the  knife  from  B  to  C,  repeating  the  first  cut  through  the 
skin. 


240  OPERATIONS  ON  THE  BREAST. 

Step  12. — This  step  did  not  belong  to  Halsted's  original  operation,  but  has 
been  added  by  him  subsequently.  Make  a  vertical  incision  parallel  to  and  near 
the  posterior  margin  of  the  sternomastoid  muscle,  dividing  a  few  of  the  posterior 
fibres  of  the  muscle.  Expose  the  junction  of  the  internal  jugular  and  sub- 
clavian veins.  Divide  the  omohyoid  muscle  at  its  tendinous  part  and  draw  its 
two  bellies  out  of  the  way.  Remove  the  supraclavicular  fat  by  dissecting 
downwards  and  outwards  from  the  venous  junction,  and  the  infraclavicular 
fat  by  dissecting  from  below.     By  elevating  the  shoulder  the  clavicle  can  be 


Fig.  321. — Skin  Incision. — {Meyer.) 

raised  an  inch  or  more  away  from  the  first  rib  when  the  operation  is  so  far 
completed  as  to  make  this  desirable.  The  web  of  fibrous  tissue  which  binds 
the  subclavian  vein  loosely  to  the  clavicle  is  thus  spread  out  and  can  be  easily 
removed.  The  fingers  can  be  passed  from  the  supracavicular  to  the  infra- 
clavicular and  to  the  subscapular  regions  under  the  clavicle,  and  any  fat  in 
the  latter  region,  near  the  internal  or  the  posterior  border  of  the  scapula  be- 
tween the  serratus  magnus  and  subscapular  muscles,  which  could  not  be  well 
reached  from  the  axilla  can  be  drawn  out  through  the  neck. 


EXCISION,    BREAST. 


241 


Fig.  322.— Insertion  of  Pectoralis  Major  Muscle  Exposed. — (Meyer.) 
Operators's  left  index  finger  encircling  its  tendon. 


Fig.  323. — Finger  Under  Tendon  of  Pector,alis  Minor  Muscle. — (Meyer.) 
Above,  cut  surface  of  clavicular  portion  of  pectoralis  major  parallel  to  clavicle  is  visible. 
(In  the  living,  the  belly  of  the  pectoralis  major  is  not  so  thoroughly  detached  from  that  of  the 
pectoralis  minor.     It  is  done  here  to  show  the  latter's  tendon.) 
16 


242 


OPERATIONS  ON  THE  BREAST. 


Step  13. — Review  the  whole  wound.  Unite  the  divided  omohyoid  by  a 
catgut  suture.  Close  the  wound  in  the  neck.  The  edges  of  the  chest  wound 
are  approximated  by  a  buried  purse-string  suture  of  strong  silk.  Of  the 
triangular  flap  of  skin  (A  B  C,  Fig.  318)  only  the  base  is  included  in  this  suture. 
The  rest  of  the  flap  is  used  as  a  lining  for  the  fornix  of  the  axilla.  The  axilla 
is  never  drained.  The  open  wound  remaining  on  the  chest  is  immediately 
covered  with  Thiersch's  skin-grafts. 


Fig.  324. — -Subclavian  and  Axillary  Veins  P^ully  Exposed. — -{Meyer.) 

So  far,  glands  and   fat  tissue   not   removed;   smaller  vessels  still  in   connection   with  main 

trunks.     Finger  under  fat  towards  sulcus  bicipitalis,  its  nail  resting  on  a.xillary  vein. 

Many  surgeons,  the  author  included,  have  devised  almost  identical  opera- 
tions for  removal  of  the  breast  and  have  found  such  satisfactory. 

Kocher's  description  of  the  operation  is  so  excellent  that  it  will  be  used  £S 
the  basis  of  the  following  paragraphs.  To  Willy  Meyer,  however,  belongs 
the  credit  of  the  radical  breast  operation  in  which  the  dissection  of  the  lymph- 
atics precedes  the  removal  of  the  mamma.  Meyer's  operation  was  devised 
totally  independently  of  Halsted's  and  was  published  during  the  same  month 
as  Halsted's. 

Step  I. — With  the  knife  make  a  few  superficial  scratches  on  the  skin  to  mark 


MEYER  S    OPERATION. 


243 


Fig.  325. — ^Operativ-e  Field.  After  Removal  of  the  Mass. — {Meyer.) 
Stump  of  pectoralis  minor  muscle  is  visible. 


Fig.  326. — Showing  Reformvtion  of  Axilla. — (Meyer) 


244 


OPERATIONS    ON   THE   BREAST. 


out  the  line  of  incision  which  is  shown  in  Fig.  319.  From  the  clavicle  to  the 
edge  of  the  anterior  axillary  fold  near  the  insertion  of  the  pectoralis  major, 
complete  the  incision  through  the  skin,  subcutaneous  tissue,  and  fascia.  Expose 
the  cephalic  vein  in  the  groove  between  the  pectoralis  major  and  deltoid,  thus 
recognizing  the  upper  edge  of  the  pectoralis.  Pass  the  finger  around  the  pector- 
alis major  one  to  two  finger-breadths  from  the  humerus.  Guided  by  the  finger, 
divide  the  pectoralis  major. 

Step  2. — The  pectoralis  minor  now  lies  exposed  to  view.  Divide  this  muscle 
near  the  coracoid  process,  and  expose  the  great  vessels  and  nerves  of  the  axilla. 

Step  3. — Beginning  above,  near  the  clavicle  and  coracoid  process,  dissect 
the  fat  from  the  axillary  vessels  and  nerves,  and  then  dissect  it  free  towards  the 


Fig.  327  — {Jackson.) 


thoracic  wall.  By  this  means  the  most  difficult  step  of  the  operation  is  com- 
pleted while  the  surgeon  is  fresh,  without  the  annoyance  of  the  loose  mass  of 
mamma,  etc.,  getting  in  the  way,  as  in  the  Halsted  operation,  and  while  the  chest 
is  still  protected  against  chill  by  its  fatty  coverings,  which  will  be  removed  later. 

Step  4. — Complete  the  incision  around  the  breast  (Fig.  319).  Excise  the 
mamma,  surrounding  fat,  and  both  pectoral  muscles.  The  wound  left  is  large 
(Fig.  320). 

Step  5. — After  attending  to  hemostasis,  close  the  wound,  as  much  as  possible, 
by  sliding  the  flaps  together.  Where  the  wound  cannot  be  closed,  cover  it 
with  Thiersch's  skin-grafts.  Provide  for  axillary  drainage  by  a  tube  intro- 
duced posteriorly. 


EXCISION,    BREAST.  245 

After  such  extensive  removal  of  important  muscles  one  would  naturally 
expect  very  serious  loss  of  function,  but  such  is  not  the  case;  the  author  has 
been  assured  by  various  patients  that  they  are  able  to  attend  to  their  own 
housework  and  to  dress  their  own  hair  satisfactorily. 

In  the  "Journ.  Am.  Med.  Assoc,"  July  29,  1905,  Willy  Meyer  published 
an  excellent  series  of  drawings  illustrating  his  operation;  these  are  so  helpful 
that  they  are  reproduced  here  without  comment  (Figs.  321  to  326). 

J.  N.  Jackson  (Fig.  327),  J.  C.  Warren  and  others  have  devised  ingenious 
incisions  for  breast  excision  the  only  fault  of  some  of  these  is  that  perhaps 
they  may  tempt  the  surgeon  to  sacrifice  thoroughness  of  extirpation  on  the  altar 
of  aestheticism. 

In  about  16  per  cent,  of  cases  of  breast  cancer,  diffusion  of  the  disease  and 
perilymphangitis  cause  obstruction  of  the  lymphatics  about  the  shoulder  and 
lead  to  oedema  of  the  arm.  The  consequent  suffering  is  often  atrocious  and 
amputation  has  often  been  performed  to  give  relief.  Handley's  operation  of 
lymphangioplasty,  is  of  value  in  treating  such  a  condition. 


CHAPTER  XXIX. 
OPERATIONS  ON  THE  CHEST. 

WOUNDS  OF  THE  LUNGS  AND  PLEUR/E. 

Wounds  of  the  lungs  and  pleurae  are  commonly  the  result  of  stabs,  bullet 
wounds,  tearmg  by  the  fractured  ends  of  ribs,  and  surgical  operations.  The 
dangers  are  hemorrhage,  shock  and  pneumothorax.  The  shock  is  largely  an 
incident  of  the  pneumothorax;  owing  to  pulmonary  retraction  due  to  pneumo- 
thorax, the  heart  and  great  vessels  lose  their  normal  support  on  one  side,  are 
displaced,  often  flop  around  and  act  in  an  inefficient  fashion.  The  teaching 
of  physiologists  leaves  the  impression  that  the  visceral  and  parietal  pleurae 
are  kept  in  apposition  entirely  by  atmospheric  pressure;  that  puncture  of  the 
pleura  inevitably  produces  pneumothorax  and  more  or  less  complete  retraction 
or  collapse  of  the  lung.  This  teaching  has  dominated  surgery  to  too  great  an 
extent.  Undoubtedly  atmospheric  pressure  is  a  very  great  factor  in  retaining 
the  normal  apposition  of  the  pleurae  but,  as  Macewen  has  shown,  a  large  flap 
of  the  chest  wall  including  the  parietal  pleura,  may  be  lifted  up,  exposing  a 
corresponding  surface  of  lung  without  pulmonary  collapse.  The  failure  of 
collapse  is  due  to  molecular  adhesion  between  the  two  pleurae  aided  by  the 
existence  between  them  of  a  thin  layer  of  serous  fluid,  i.  e.,  the  apposed  surfaces 
of  pleura  are  moist.  If  the  finger  is  passed  around  the  wound  and  separates 
the  visceral  from  the  parietal  pleura  air  enters  and  a  certain  amount  of  collapse 
occurs,  but  if  the  elastic  chest  wall  is  pressed  inwards  so  that  the  parietal  pleura 
is  allowed  to  come  once  more  into  free  contact  with  the  visceral,  then  the  lung 
again  expands.  These  remarks  of  course  apply  only  to  the  healthy  pleura,  as 
in  a  pleura  roughened  by  ridges  and  masses  of  exudates  and  conditions  are 
entirely  different. 

The  above  principles  and  observations  of  Macewen's  were  the  basis  of  suc- 
cessful treatment  in  a  number  of  serious  wounds  reported  by  him.  ("Brit. 
Med.  Journ.,"  July  7,  1906.) 

Elsberg  ("Med.  Record,"  May  23,  1908)  finds  that  the  weight  of  the  heart 
pulls  it  backwards  and  makes  tense  the  pleural  covering  of  the  anterior  medi- 
astinum when  the  patient  is  in  the  dorsal  decubitus  and  thus  predisposes  to 
pneumothorax  when  the  pleura  is  wounded.  If  the  patient  is  placed  in  the 
ventral  position  pneumothorax  is  much  less  likely  to  arise.  Lilienthal  has 
applied  Elsberg's  findings  with  success  in  twenty-one  cases  in  which  the  pleural 
cavity  was  opened  and  no  interference  with  the  mechanism  of  respiration  re- 
sulted. [Lilienthal's  cases  comprised  a  number  of  empyemas,  two  liver  ab- 
scesses, five  subphrenic  abscesses  and  one  left-sided  bronchiectasis.] 

246 


WOUNDS    OF    PLEURA.  247 

Methods  of  Keeping  up  Respiration  zvhen  the  Thorax  is  Freely  Opened. — 
When  one  side  of  the  thorax  is  freely  opened  respiration  becomes  much  em- 
barrassed; when  both  sides  are  freely  opened  it  becomes  impossible  under 
ordinary  circumstances.  Matas  and  a  number  of  others  devised  more  or  less 
complicated  means  by  which  air  from  a  bellows,  or  its  equivalent,  could  be 
pumped  through  the  nose,  the  mouth  or  a  tracheal  cannula  alternately  into 
and  out  from  the  lungs  ("Trans.  Am.  Surg.  Assoc,"  vol.  xix).  Richter 
("Surg.,  Gyn.,  Obstet.,"  Nov.,  1908)  modified  the  pump  method.  In  his  ap- 
paratus the  necessary  air  is  stored  in  a  tank  under  high  pressure.  As  re- 
quired, air  is  conducted  from  the  tank  to  a  rubber  balloon  where  it  can  be 
kept  at  a  moderate  pressure.  From  the  balloon  the  air  is  led  through  a 
rubber  tube  to  a  tracheal  cannula  and  so  into  the  lungs.  An  ingenious  and 
simple  electric  valve  permits  air  to  flow  into  the  lung  at  proper  and  regulated 
intervals,  and  l^etween  these  intervals  permits  it  to  escape.  Another  devise 
permits  the  administration  of  an  anaesthetic.  Richter  demonstrated  his 
method  to  the  members  of  the  Society  of  Clinical  Surgery.  Meltzer  and 
Auer  have  described  a  method  of  artificial  respiration  which  they  name 
"respiration  by  the  continuous  intratracheal  insufflation  of  air."  A  small 
tube  is  passed  through  the  larynx  into  the  trachea  almost  to  the  bifurca- 
tion, and  by  means  of  a  foot-bellows  air  mixed  with  ether  is  blown  almost 
continuously  through  the  tube  under  a  pressure  of  15  to  20  mm.  of  mercury. 
The  lungs  are  kept  moderately  distended,  the  blood  is  aerated  and  the  excess 
air  escapes  along  side  the  tube.  The  method  has  been  used  successfully  by 
Carrel  and  Elsberg  ("Annals  Surg.,"  July,  1910)  in  many  operations  on  the 
thoracic  viscera.  The  author  has  used  the  Meltzer-Auer  method  in  experi- 
mental work  on  rabbits  using  instead  of  the  foot-bellows  a  simple  hydrostatic 
air  compressor  extemporized  by  Sutton.  Elsberg  suggests  "the  tube  that  is 
to  be  introduced  into  the  trachea  should  be  a  fairly  rigid  one  of  rubber  with  an 
opening  at  its  lower  end.  It  should  be  as  long  as  an  ordinary  stomach-tube. 
Tubes  of  various  sizes  should  be  kept  on  hand.  The  tube  to  be  used  in  a  given 
case  should  fill  up  about  one-half  of  the  lumen  of  the  trachea.  One  can  obtain 
a  sufficiently  accurate  idea  of  the  size  to  be  used  by  estimating  the  diameter 
of  the  trachea  at  the  root  of  the  neck."  Lilienthal  and  Elsberg  have 
applied  the  method  successfully  in  the  human  being.  To  the  author  it 
appears  that  the  continuous  insufiSation  of  air  will  probably  become  the 
method  of  choice  for  keeping  up  artificial  respiration  during  intrathoracic 
operations. 

Sauerbruch  was  the  first  to  devise  a  cabinet  by  means  of  which  the  thorax 
could  be  freely  opened  and  respiration  kept  up  under  the  force  of  either  negative 
or  positive  pressure.  Brauer  constructed  a  rather  clumsy  apparatus  for  keeping 
up  respiration  under  positive  pressure.  Willy  Meyer  and  his  brother  (an 
engineer)  have  constructed  a  very  efficient  cabinet  for  both  negative  and  positive 
pressures.  It  would  be  out  of  place  to  describe  here  the  structure  and  methods 
for  the  employment  of  any  of  the  pneumatic  cabinets,  each  of  which  has  its 


248  OPERATIONS  ON  THE  CHEST. 

advantages  and  disadvantages;  it  will  be  sufl&cient  to  give  the  principles  on  which 
they  work. 

Negative  Pressure  Cabinet. — The  surgeon,  his  assistants  and  the  patient's 
body  are  inside  the  cabinet.  The  patient's  head  protrudes  through  a  hole  in 
the  wall  of  the  cabinet  his  neck  being  surrounded  by  an  air-tight  collar.  By 
means  of  an  air  pump,  controlled  by  a  manometer,  the  air  pressure  inside  the 
cabinet  is  lowered  sufficiently  to  permit  of  respiration  after  the  thorax  is  opened. 

Positive  Pressure  Cabinet. — Same  as  negative  pressure  cabinet  except  that 
the  patient's  body  is  outside  while  his  head  and  the  anaesthetist  are  inside 
the  cabinet.  By  means  of  an  air  pump  the  pressure  of  the  air  inside  the  cabinet 
is  increased. 

Artificial  respiration  by  insufflation  of  air  or  by  differential  pressure  apparatus 
must  necessarily  be  of  inestimable  value  in  operations  on  the  lungs,  the  chest 
wall  and  the  oesophagus.  Carrel's  researches  show  that  probably  surgery  may 
in  the  future  offer  a  cure  for  many  of  the  diseases  of  the  heart  and  great  vessels. 
These  researches  were  carried  out  on  animals  kept  alive  by  the  Meltzer-Auer 
air  insufflation.  The  whole  subject  of  intrathoracic  surgery  is  in  such  a 
seething  state  of  development  that  it  is  impossible  to  discuss  the  recently 
devised  operations  and  methods  in  such  a  work  as  the  present.  The  author 
endeavored  to  write  a  review  of  the  recent  advances  in  this  field  but  found 
that  it  was  impossible  for  him  to  do  so  intelligently  without  occupying  far 
too  much  space  and  that  even  then  the  student  would  require  to  consult  the 
original  articles  of  the  experimenters. 

A.  Treatment  of  Wounds  Penetrating  the  Chest. — Do  not  let  the  patient 
lie  on  the  healthy  side.  To  do  so  directly  interferes  with  the  motion  of  that 
part  of  the  chest;  it  also  favors  the  entrance  of  air  into  the  wound  and  conduces 
to  separation  of  the  two  layers  of  the  wounded  pleura. 

Exert  steady  pressure  on  the  injured  side  of  the  chest,  also,  if  necessary, 
on  the  hypochondrium  of  that  side  to  support  the  diaphragm.  If  necessary 
administer  a  general  anaesthetic,  but  no  not  produce  deep  anaesthesia. 

Enlarge  the  wound  sufficiently  to  permit  exploration,  removal  of  foreign 
materials,  cleansing  and  hemostasis.  If  advisable  remove  a  segment  of  one  or 
more  ribs.  Steady  pressure  on  the  chest-wall  may  be  sufficient  to  keep  the 
pleurae  in  apposition  or  to  bring  them  into  apposition  if  they  have  been  separated 
by  the  trauma  or  during  necessary  exploration  with  finger  or  probe.  If  there 
is  a  wound  of  the  lung,  examine  it,  remove  any  foreign  bodies,  attend  to  hemo- 
stasis by  means  of  pressure  with  hot  pads  of  gauze,  of  ligatures  or  of  catgut 
sutures.  Close  the  pulmonary  wound.  Loosely  pack  the  wound  in  the  chest- 
wall  with  gauze  and  partly  close  the  external  wound.  Apply  dressings  and 
immobilize  the  affected  side  of  the  chest  with  strapping  applied  tightly,  as  in 
the  case  of  fractured  ribs. 

If  pressure  on  the  chest-wall  fails  to  obtain  and  retain  pleural  contact  it  may 
possibly  be  a  good  plan  to  unite  the  wound  in  the  lung  to  that  in  the  chest-wall 
by  a  stitch. 


PNEUMOTHORAX.  249 

The  use  of  drainage  by  a  loose  pack  is  important,  as  otherwise  effusions 
from  the  wound  passing  between  the  two  pleural  membranes  might  cause  much 
trouble;  the  drain  also  permits  air  escaping  from  the  pulmonary  wound  to  pass 
out  through  the  chest-wall. 

Le  Conte  has  had  a  large  experience  with  penetrating  wounds  of  the  chest 
and  finds  the  best  means  of  stopping  bleeding  from  the  lung  to  be  by  the  produc- 
tion of  pneumothorax.  Le  Conte's  views  are  so  different  from  those  usually 
propounded  and  his  judgment  is  so  good  that  it  is  well  to  reprint  his  con- 
clusions. 

"My  conclusions  are,  then,  that  when  the  wound  of  the  lung  is  giving  only 
slight  hemorrhage,  close  the  external  wound  with  gauze  and  watch  for  the 
physical  signs  of  bleeding.  When  the  hemorrhage  is  more  marked,  open  the 
chest,  insert  a  small  drainage-tube,  and  regulate  the  admission  of  air  according 
to  the  difficulty  of  respiration  in  the  patient.  When  the  hemorrhage  is  large 
and  its  symptoms  alarming,  open  the  chest  and  insert  a  large  drainage-tube, 
so  as  to  form  a  rapid  and  complete  pneumothorax,  and  at  the  same  time,  when 
necessary,  inject  salt  solution  into  a  vein.  When  this  does  not  control  the 
hemorrhage,  resect  one  or  more  ribs,  and  deal  radically  with  the  bleeding.  In 
severe  hemorrhage  from  a  lung,  the  first  object  of  treatment  should  be  to  get 
pressure  on  that  lung.  By  opening  the  chest,  air  will  do  this  as  well  as  blood 
in  the  pleura;  it  will  do  it  instantly  instead  of  waiting  until  a  sufficient  amount 
of  blood  has  been  poured  out;  it  will  save  to  the  patient  the  amount  of  blood 
necessary  to  exert  this  mechanical  pressure;  it  will  permit  the  vessel  to  close  by 
clots;  and  the  remote  benefits  are  that  it  eliminates  the  dangers  of  a  pyothorax 
or  of  universal  adhesions  of  the  pleura.  The  danger  from  engorgement  of  the 
right  side  of  the  heart  must  be  slight  where  the  patient  has  lost  much  blood. 
Because  it  is  a  great  danger  in  a  full-blooded  dog  is  no  reason  why  it  should  be 
so  in  an  exsanguined  man,  for  the  conditions  are  different  and  the  cases  not 
parallel.  It  is  only  fair  for  me  to  tell  you  that  these  views  are  my  own,  and  are 
not  indorsed  by  the  majority  of  surgeons,  but  I  give  them  to  you  because  they 
are  the  result  of  my  experience  and  because  they  seem  to  me  logical  and 
correct." 

B.  Treatment  of  Pnetunothorax  Resulting  from  Fracture  of  a  Rib. — 
The  indications  for  operative  treatment  are  great  respiratory  distress  and  cya- 
nosis with  embarrassed  heart  action.      The  methods  of  treatment  are  two: 

(a)  Aspiration. — This  gives  immediate  relief.  If  the  wound  in  the  lung 
closes  and  becomes  sealed  against  the  further  escape  of  air,  the  relief  is  per- 
manent. If  the  lung  wound  remains  open,  e.  g.,  from  its  size,  from  a  shred  of 
visceral  pleura  being  pushed  into  it,  etc.,  the  symptoms  will  promptly  recur  and 
operation  becomes  urgent. 

(6)  Expose  the  fractured  rib  or  ribs  by  incision  (preferably  vertical) ;  excise 
enough  of  one  or  more  ribs  to  gain  access  to  the  wound  in  the  lung.  Keep  up 
pressure  on  the  thoracic  wall.  An  advantage  of  incomplete  or  of  no  ana.'sthesia 
is  that  the  patient  may  be  made  to  cough,  sneeze,  struggle,  etc.,  and  so  force  the 


250  OPERATIONS    ON    THE    CHEST. 

lung  towards  the  wound.     Treat  the  wound  exactly  as  in  the  case  of  a  stab 
wound. 

C.  Emphysema  Resulting  from  a  Fractured  Rib. — The  emphysema 
may  or  may  not  be  accompanied  by  marked  pneumothorax.  Macewen 
{loc.  cit.)  has  shown  that  the  emphysema  results  from  the  lung  tissue  being 
hooked  on  to  the  spiculae  at  the  fractured  end  of  the  rib  and  a  free  path  being 
established  between  the  injured  lung  and  the  lacerated  subcutaneous  tissues. 
Logically  the  operative  treatment  is  identical  with  that  for  any  other  lung  wound. 

OPERATIONS  ON  THE  PLEURAL  CAVITY. 

Exploratory  Puncture. — The  existence  of  fluid  in  the  pleural  cavity  is 
diagnosed  or  suspected;  by  exploratory  puncture  its  presence  and  character  are 
determined.  Choose  a  point  on  the  chest-wall  corresponding  to  the  location  of 
the  suspected  fluid.  Clean  the  skin  thoroughly.  Choose  a  hypodermic  syringe 
with  a  long  and  not  too  fine  needle  and  sterilize  them.  Insert  the  needle  into 
the  pleural  cavity  at  a  point  just  above  a  rib.  This  avoids  danger  of  injuring 
the  intercostal  vessels.  Slowly  withdraw  the  piston  of  the  syringe.  If  fluid  is 
found,  preserve  it  for  examination;  if  it  is  not  found,  the  operation  should  be 
repeated  at  several  points  and  the  needle  examined  after  each  withdrawal 
lest  it  should  have  become  plugged.     No  dressings  are  required. 

Thoracentesis. — The  object  of  the  operation  is  the  removal  of  fluid  from 
the  pleural  cavity.  The  operation  may  be:  (a)  Exploratory.  The  fluid 
withdrawn  is  examined  microscopically.  If  tuberculosis  is  suspected,  the 
examination  should  include  the  inoculation  of  guinea-pigs,  {b)  Therapeutic. 
In  adults  when  the  fluid  is  not  infected,  the  operation  is  curative.  In  children 
even  when  the  fluid  is  infected  a  cure  often  results. 

Strict  asepsis  must  be  maintained;  othervnse  a  simple  effusion  into  the  pleural 
cavity  may  be  converted  into  an  empyema,  or  to  the  bacteria  which  have 
already  produced  an  empyema  there  may  be  added  others  which  may  markedly 
increase  the  intensity  and  gravity  of  the  disease.  Dennis  advocates  surround- 
ing with  rubber  sheets  the  area  to  be  washed,  so  as  to  avoid  chilling  the  patient 
unnecessarily  with  the  antiseptic  washes.  The  patient  should  be  placed  in 
a  semi-erect  posture,  if  necessary  being  propped  up  with  pillows.  If  he  is 
weak,  give  him  a  stimulant  of  strychnine  or  alcohol. 

The  favorite  points  for  operation  are  the  eighth  intercostal  space  near  the 
angle  of  the  scapula  and  the  sixth  near  the  midaxillary  line.  Clean  the  patient's 
skin.  If  desired,  inject  a  few  drops  of  a  2  per  cent,  solution  of  cocaine  into 
the  skin  at  a  point  over  the  rib  near  its  upper  edge.  With  a  fine  knife  make 
a  puncture  through  the  skin  at  this  point.  Pull  the  skin-wound  upwards 
so  that  the  needle  of  a  Potain  aspirator  (thoroughly  disinfected)  can 
now  be  introduced  and  made  to  pass  into  the  chest  in  contact  or  nearly  so  with 
the  upper  edge  of  the  rib.  The  object  of  puncturing  the  skin  with  the  knife 
is  that,  the  skin  being  tough,  so  much  force  is  required  to  push  the  aspirating 


THORACOTOMY.  25 1 

needle  through  it  that,  the  skin  once  passed,  the  needle  is  liable  to  be  jerked  into 
the  tissues.  Another  reason  is  that  disinfection  of  the  deep  layers  of  the  skin 
being  practically  impossible,  the  needle  cutting  its  way  through  may  conceiv- 
ably become  infected  and  do  harm. 

In  whatever  way  the  skin  is  penetrated,  the  puncture  through  it  should  not 
be  opposite  that  through  the  deep  structures;  a  valvular  wound  is  desired.  The 
needle  is  made  to  hug  the  upper  edge  of  a  rib  so  as  to  avoid  injuring  intercostal 
vessels.  Having  introduced  the  needle,  aspiration  is  begun.  If  fluid  does  not 
come,  this  may  be  due  to  the  needle  having  become  clogged  with  tissue  or  a 
clot  of  fibrinous  material.  A  stilette  passed  through  the  needle  will  free  its 
lumen.  If  obstruction  to  the  lumen  is  not  the  cause  of  failure  to  obtain  fluid, 
the  needle  should  be  partially  withdrawn  and  reintroduced  in  another  direction. 
Working,  as  one  does,  in  the  dark,  several  punctures  may  be  necessary  before 
the  fluid  is  found  or  one  is  satisfied  that  it  is  absent. 

WQien  the  fluid  flows,  let  it  flow  slowly.  If  the  patient  coughs  or  has  a  feeling 
of  oppression,  stop  the  flow  until  he  recovers.  The  same  must  be  done  if  the 
pulse  alters  markedly  or  the  patient  becomes  faint.  As  the  fluid  escapes  the 
patient  may  be  lowered  in  his  bed.  If  the  effusion  is  great,  it  is  wise  to  stop 
the  operation  before  the  fluid  is  nearly  all  removed.  The  remainder  may  be 
absorbed.     The  sudden,  complete  emptying  of  the  sac  is  likely  to  do  harm. 

Pleurisy  Blocquees. — Occasionally  all  the  physical  signs  of  fluid  being 
in  the  pleura  are  present,  the  aspirating  needle  is  inserted  but  no  fluid  flows. 
Examination  of  the  needle  shows  no  plugging  of  its  lumen.  Dufour,  in  1905, 
showed  that  old  pleuritic  effusions  exist  which  cannot  be  aspirated  by  ordinary 
means  while  Mosny  and  Stern  ("La  Presse  Med.,"  Dec.  11,  1909)  demon- 
strated the  same  regarding  certain  recent  acute  pleurisies.  The  reason  for 
the  failure  of  aspiration  is  that  the  fluid  happens  to  be  in  a  cavity  with  rigid 
walls,  e.  g.,  a  cavity  whose  walls  may  consist  of  hepatized  lung,  the  chest  wall 
and  pleuritic  adhesions.  If,  as  occasionally  happens,  the  tension  of  the  fluid 
is  about  equal  to  that  of  the  atmosphere,  then  only  a  small  amount  of  the 
fluid  will  escape  through  the  aspirating  needle;  if  the  tension  of  the  fluid  is  less 
than  that  of  the  atmosphere,  no  fluid  will  escape.  If  a  second  hollow  needle 
is  passed  alongside  the  aspirating  needle,  atmospheric  air  will  be  admitted 
into  the  cavity  and  aspiration  becomes  easy. 

Thoracotomy. — The  object  of  thoracotomy  is  to  drain  the  pleural  cavity. 
Local  or  general  anaesthesia  may  be  employed,  preferably  local.  Make  an 
incision  two  inches  in  length  parallel  to  the  ribs  at  a  point  just  anterior  to  the 
edge  of  the  latissimus  dorsi  muscle  and  corresponding  to  the  sixth,  seventh, 
or  eighth  intercostal  space.  Along  the  lower  border  of  the  space  cut 
through  the  intercostal  muscles.  Attend  to  hemostasis.  Make  a  small  open- 
ing through  the  parietal  pleura.  Too  rapid  evacuation  of  the  pus  is 
dangerous,  as  it  too  suddenly  alters  conditions  of  intrathoracic  pressure. 
As  the  pus  flows,  enlarge  the  opening  with  forceps  or  the  finger.  Explore 
the  empyema  cavity  with  the  finger  and  remove  all  shreds  of  tissue  or  clots  of 


252 


OPERATIONS    ON   THE    CHEST. 


fibrin  floating  in  the  cavity.  If  such  are  left  behind,  they  are  liable  to  interfere 
with  drainage  and  delay  recovery.  Do  not  irrigate  the  cavity.  This  has  proved 
dangerous.  Above  all,  do  not  use  antiseptic  irrigation.  Drain  by  means  of 
tubes  passed  into  the  pleural  cavity.  Not  much  of  the  tube  should  project 
into  the  pleura.  The  tubes  may  be  rigid  or  soft.  The  writer  generally  uses  a 
portion  of  a  large  soft-rubber  catheter.  To  prevent  the  tube  slipping  into  the 
pleura  either  stitch  it  to  the  skin  or  transfix  it  with  a  large  safety-pin.  If  neces- 
sary (it  rarely  is  necessary),  partially  close  the  skin-wound  with  sutures.  Sur- 
round the  outer  end  of  the  drain  with  sterile  gauze  in  bird-nest  fashion.  This 
prevents  direct  pressure  on  the  tube.  Apply  abundant  dressings.  Some 
surgeons  place  oiled  silk  over  the  mouth  of  the  drainage-tube  to  act  as  a  valve, 
allowing  the  escape  but  not  the  entrance  of  air  into  the  pleura.  This  is  unneces- 
sary. After  the  pleura  has  been  penetrated,  a 
counteropening  may  seem  desirable.  To  make 
this,  pass  a  forceps  through  the  wound,  through 
the  cavity,  and  with  its  point  elevate  the  tissues 
at  the  position  selected.  Cut  down  on  the 
forceps  and  push  them  through  the  new  wound. 
Grasp  a  perforated  rubber  tube  in  the  jaws  of 
the  forceps  and  pull  the  tube  through  the  cavity. 
This  provides  efficient  through-and-through 
drainage.  Ochsner  is  a  great  advocate  of 
through-and-through  drainage.  If  at  any  time 
it  is  desired  to  withdraw  the  tube  and  intro- 
duce another,  fasten  a  stout  thread  to  the  end 
of  it  and  in  withdrawing  the  tube  pull  the 
thread  through  the  cavity;  with  this  thread  in 
situ  it  is  easy  to  introduce  another  tube.  Later  the  tube  may  be  replaced  by  a 
few  strands  of  silkworm-gut.  Tubular  drainage  must  be  kept  up  until  all  dis- 
charge has  ceased.  In  cases  of  pneumococcic  infection  recovery  is  usually 
rapid,  the  lung  expanding  and  obliterating  the  empyema  cavity.  When  the 
infection  is  streptococcic,  many  weeks  may  elapse  before  the  infected  cavity  be- 
comes obliterated.  Some  surgeons  to  make  drainage  more  perfect  and  con- 
tinuous, connect  the  drainage-tube  to  a  pipe  passing  through  the  dressings  and 
attached  to  a  Bunsen's  air  pump  (Fig.  328).  This  ingenious  measure  is  not 
often  required.  During  the  after-treatment  of  cases  of  thoracotomy  the  patient 
should  be  placed  in  the  position  found  at  the  operation  to  be  most  favorable  for 
drainage.  This  position,  especially  if  disagreeable,  need  not  be  kept  up  con- 
tinuously, but  adopted  at  intervals  for  a  short  time.  It  is  wise  to  encourage 
the  patient  to  sit  up  and  move  about  at  as  early  a  date  as  possible.  Fresh 
air  is  of  great  value  in  treatment. 

Kutherford  Morison  thinks  that  an  incision  parallel  to  the  ribs  is  likely 
to  kink  the  tube  {a)  during  respiratory  movements,  (6)  from  altered  position 
after  completion  of  operation.     He  operates  as  follows: 


THORACOTOMY.  253 

1.  Verify  presence  of  pus  with  hypodermic  syringe. 

2.  Make  a  vertical  incision  down  to  rib  and  across  intercostal  space. 

3.  Push  a  sinus  forceps  (a  closed,  fine-pointed  hemostat  is  satisfactory) 
into  pleural  cavity.     Alongside  the  forceps  introduce  a  director. 

4.  Open  the  forceps  parallel  to  the  ribs  and  pull  them  out  while  open,  but 
leave  the  director  in  situ.     (This  method  avoids  hemorrhage.) 

5.  Guided  by  the  director,  introduce  drainage-tube. 

Continue  tubular  drain  until  there  is  no  more  pus  than  can  be  accounted 
for  by  the  external  wound.  After  removal  of  tube  introduce  director  daily 
so  as  to  discover  if  pus  reforms  necessitating  reintroduction  of  tube. 

Thoracotomy  with  resection  of  a  segment  of  rib  is  usually  much 
preferable  to  simple  intercostal  incision.  In  the  latter  the  space  is  limited, 
finger  exploration  is  difficult  or  impossible,  and  when  the  tube  is  introduced, 
it  is  very  liable  to  be  pinched  between  the  ribs  and  rendered  useless.  Removal 
of  a  segment  of  one  or  more  ribs  does  no  permanent  harm  and  the  operation  is 
exceedingly  easy.  Excision  of  a  segment  of  rib  is  rarely  required  in  children 
and  as  rarely  should  it  be  omitted  in  adults.  In  operating  on  non-localized 
empyema  the  incision  may  be  made  over  the  sixth  or  seventh  rib  in  the  mid- 
axillary  line,  or  over  the  ninth  rib  just  external  to  the  angle  of  the  scapula, 
which  is  the  best  position.  In  cases  of  localized  empyema  the  opening  must 
of  course  be  made  over  the  encapsulated  pus.  When  incision  is  made  in  the 
mid-axillary  line,  the  patient  must  be  brought  to  the  edge  of  the  table  over 
which  the  affected  side  may  protrude  a  little.  When  the  posterior  site  of  opera- 
tion is  chosen,  place  the  patient,  with  the  sound  side  uppermost,  in  a  position 
midway  between  the  lateral  and  ventral — i.  e.,  lying  half  over  on  his  belly. 
The  sound  side  must  never  he  undermost,  otherwise  respiration  will  be  impeded. 
The  surgeon  under  these  circumstances  stands  in  front  of  the  patient  and 
reaches  the  site  of  the  operation  by  leaning  over  him. 

These  are  the  classical  instructions  always  insisted  on  but  rarely  carried 
out,  except  in  trivial  cases  or  by  beginners  who  are  much  hampered  by  them. 
They  are  impracticable.  In  Friedrich's  most  extensive  pneumolysis,  the 
patient  lies  on  the  sound  side.  The  researches  of  Schafer  (Transactions, 
Section  on  Surg,  and  Anat.,  American  Med.  Assoc,  1908)  on  artificial 
respiration  and  the  experiments  and  observations  of  Elsberg,  clearly  show  that, 
when  possible,  the  prone  position  is  the  position  of  choice  for  operations  on  the 
chest.  Sauerbruch's  cabinet  might  be  of  value  but  unfortunately  it  is  still 
in  a  stage  of  development  which  places  it  beyond  the  reach  of  almost  all  surgeons. 
The  other  devices  for  carrying  on  respiration  under  positive  or  negative  pressure 
(Brauer's,  Matas',  Samuel  Robinson's,  Green's  and  Maury's,  etc.)  are  not  yet 
sufficiently  simplified  for  common  use.  Richter's  apparatus  is  most  promising. 
("Surg.,  Gyn.,  Obstet.,"  Nov.,  1908.)  Macewen's  researches  into  the  mechan- 
ism of  respiration  may  lead  to  changes  in  method  of  work.  At  present  it  is  im- 
possible to  dogmatize  regarding  thoracic  surgery. 

The  Operation. — i.  Make  an  incision  two  to  three  inches  in  length  along  the 


2t;4  OPERATIONS    ON    THE    CHEST. 

long  axis  of  the  chosen  rib  and  divide  the  periosteum  along  a  line  midway 
between  the  upper  and  lower  borders  of  the  rib. 

2.  With  a  curved  periosteal  elevator  separate  the  periosteum  form  the  bone 
both  externally  and  internally.  The  intercostal  vessels  are  separated  from 
the  bone  with  the  periosteum.  In  recent  cases  much  care  must  be  exercised 
when  detaching  the  periosteum  from  the  deep  surface  of  the  bone  lest  the 
pleura  be  prematurely  opened;  in  cases  of  long  duration  there  is  so  much 
pleural  thickening  that  no  accident  is  likely  to  happen. 

3.  Divide  the  exposed  rib  at  the  posterior  end  of  the  wound  with  bone 
forceps  or  rongeurs.  For  this  purpose  a  costotome  (Fig.  329)  is  convenient 
but  not  necessary.  Grasp  the  portion  of  bone  to  be  removed  in  the  jaws  of  a 
sequestrum  forceps,  steady  and  bring  it  forwards,  and  divide  it  anteriorly 
with  bone  forceps.     Two  inches  of  bone  should  be  removed. 


Fig.  329. 

4.  Make  a  small  incision  through  the  deep  layer  of  periosteum  and  the 
pleura.  Let  the  pus  flow  out  slowly.  Interrupt  its  flow  from  time  to  time 
by  plugging  the  wound  with  gauze.  Too  rapid  evacuation  means  pulmo- 
nary congestion,  and  this  is  liable  to  cause  fatal  anaemia  of  the  brain.  Proceed 
as  in  thoracotomy.  If  the  cavity  is  large,  it  is  easy  to  resect  portions  of  two 
ribs  subperiosteally  through  the  same  external  incision.  If  this  is  done,  the 
intercostal  muscles  and  vessels  should  be  ligated  behind  and  in  front  of  the 
pleural  incisions  and  the  two  horizontal  openings  into  the  pleura  united  by 
a  vertical  cut  to  form  an  H-shaped  wound  (Fig.  330). 

After  thorough  removal  of  clots  of  fibrin  and  necrosed  tissue.  Beck  irri- 
gates with  salt  solution,  or  if  the  pus  is  foul,  with  bichloride  of  Mercury 
(i  :  5000).  [Most  surgeons  condemn  the  irrigation.]  If  there  is  much  shock 
or  hemorrhage  put  off  the  evacuation  of  solid  material  and  the  use  of  irriga- 
tion for  a  day  or  two.  Beck  now  stitches  the  costal  pleura  to  the  skin  (pleur- 
ostomy)  and  packs  the  pus  cavity  with  3  per  cent,  iodoform  gauze  in  the 
form  of  a  long  narrow  strip  with  selveged  edges.  The  packing  is  done  tightly 
for  the  first  twenty-four  hours  in  order  to  prevent  hemorrhage,  later  on 
loosely.  No  subsequent  irrigation  is  necessary.  The  packing  after  the 
first  few  days  does  not  usually  require  to  be  changed  oftener  than  every  second 


THORACECTOMY. 


255 


or  third  clay.     Beck  claims  that  the  gauze  soaking  the  pus  into  itself  removes 
it  from  the  pleural  surfaces  better  than  does  a  drainage-tube. 

The  cure  of  an  empyema  by  drainage  depends,  tirst,  on  the  free  escape 
of  the  pus;  and,  second,  on  expansion  of  the  lung  obliterating  the  pleural 
cavity  and  permitting  the  more  or  less  complete  adhesion  of  the  parietal  and 
visceral  layers  of  the  pleura.  WTien  the  lung  is  unable  to  expand  and 
approach  the  chest-wall,  obliteration  of  the  cavity  may  be  obtained  by 
bringing  the  chest-wall  to  the  lung.  To  accomplish  this  is  the  object  of 
thoracoplasty.  Before  deciding  for  or  against  thoracoplasty  it  is  of  prime 
importance  to  know  whether  or  not  the  lung  is  capable  of  expanding  suf- 
ficiently to  fill  the  thoracic  cavity.  For  this  purpose  Perles'  method  of  ex- 
amination is  good.  (F.  Karewski,  "Die  deutsche  Klinik,"  viii,  313.)  It  is  as 
follows: 


=^^ 


Fig    330. 


Fig.  3: 


I.  Measure  the  capacity  of  the  cavity  by  pouring  into  it  an  indifferent 
liquid  from  a  vessel  holding  a  known  quantity.  When  the  cavity  is  full,  it 
is  easy  to  calculate  its  capacity  by  noting  the  amount  of  liquid  left  in  the  vessel 
and   subtracting  it  from  the   amount  originally  in   it. 

II.  Measurement  of  the  expansile  power  of  the  lung:  The  drainage- 
tube  or  cannula  emerging  from  the  empyema  is  connected  by  a  tube  to  the 
graduated  cylinder  x  (Fig.  331),  at  the  top  of  which  is  a  stopcock  (s)  and 
at  the  bottom  a  tube  leading  to  a  jar  of  water  (d).  The  stopcock  is  closed 
and  the  cylinder  and  lower  tube  are  full  of  water.  Atmospheric  pressure 
prevents  the  water  leaving  x  as  long  as  the  stopcock  s  remains  closed.  Open 
s,  and  at  once  the  water  in  the  cylinder  x  falls,  aspirating  air  from  the  empyema 
cavity  as  long  as  the  lung  continues  to  expand.  Whenever  the  water  in  the 
cylinder  rises  and  falls  with  the  patient's  inspiration  and  expiration,  it  shows 
that  the  lung  has  approached  the  chest-wall  as  closely  at  it  can.  The  amount 
of  air  now  in  the  cylinder  (x)  can  be  read  on  the  graduated  scale,  and  repre- 
sents how  much  the  empyema  cavity  has  been  diminished  by  lung 
expansion. 

Compare  the  results  obtained  by  these  two  methods  of  examination.     If 


256  OPERATIONS    ON    THE    CHEST. 

the  capacity  of  the  cavity  (known  by  Method  I)  is  not  very  different  from 
the  expansile  power  of  the  lung  (Method  II),  then  it  is  wise  not  to  proceed 
to  thoracoplasty  before  trying  some  method  of  suction  drainage.  If  there 
is  a  marked  difference  between  the  capacity  of  the  cavity  and  the  expansile 
power  of  the  lung,  thoracoplasty  is  proper. 

Estlander's  Operation. — Make  a  subperiosteal  resection  of  three  or  four 
ribs  (about  4  inches  of  each)  through  separate  incisions,  exactly  as  in  thor- 
acotomy with  resection  of  rib.  Instead  of  using  separate  skin-incisions  the 
ribs  may  be  exposed  by  a  U-,  T-,  H-,  or  I-shaped  incision,  the  soft  parts 
being  reflected  as  a  flap  or  flaps,  and  then  the  ribs  resected  subperiosteally. 
This  operation  permits  a  falling-in  of  the  chest-wall,  but  in  many  cases  the 
parietal  pleura  is  so  thick  and  hard  that  it  is  inelastic,  and  the  desired  re- 
traction of  the  chest  cannot  take  place.  To  obtain  proper  retraction  the 
following   procedure   has    been    adopted: 

Schede's  Operation  (Thoracoplasty). — Beginning  at  the  origin  of  the  pec- 
toralis  major  at  the  level  of  the  axilla  make  an  incision  which  goes  downwards 
in  a  curve  to  the  bottom  of  the  pleural  sac, — i.  e.,  the  tenth  rib  in  the  poste- 
rior axillary  line, — crosses  the  chest-wall  from  the  front  to  the  back,  and 
ascends  to  the  level  of  the  second  rib  at  a  point  between  the  spine  and  the 
scapula.  Reflect  upwards  the  huge  flap  thus  outlined,  and  include  in  it  all 
the  tissues  superficial  to  the  ribs  and  intercostal  muscles.  Resect  subperi- 
osteally all  the  ribs  over  the  cavity,  from  their  tubercles  to  their  insertion 
into  the  costal  cartilages.  To  do  this  it  is  best  to  divide  the  rib  at  its  middle 
with  bone  forceps,  and,  grasping  the  divided  end  of  one  of  the  fragments 
with  sequestrum  forceps,  dissect  it  out  of  its  periosteal  bed.  The  other  frag- 
ment is  removed  in  the  same  fashion. 

Bardenheuer  has  been  compelled  to  excise  even  the  first  rib,  the  clavicle,  and  the 
scapula  before  he  could  obtain  a  satisfactory  result. 

Make  a  large  incision  through  the  thickened  pleura  to  permit  of  thorough 
exploration.  This  exploration  tells  how  many  ribs  must  be  excised  and  to 
what  extent.  Excise  all  the  periosteum,  intercostal  muscles,  and  thickened 
pleura  over  the  empyema  cavity.  There  is  not  liable  to  be  much  hemorrhage 
from  the  intercostal  vessels,  owing  to  their  being  more  or  less  obliterated 
by  the  disease,  but  the  patients  are  usually  debilitated,  the  operation  is  very 
severe,  and  hence  it  is  necessary  to  clamp  and  ligate  all  the  intercostal  vessels. 
Hemostasis  must  be  very  carefully  attended  to.  Some  surgeons  carefully 
scrape  away  all  diseased  granulation  tissue,  but  all  that  is  necessary  is  gentle 
wiping  with  gauze  pads.  Replace  the  flap  of  soft  parts.  This  flap,  at  least 
if  the  disease  has  been  extensive,  will  not  by  any  means  cover  the  defect, 
as  its  under  or  raw  surface  must  be  in  contact  with  the  outer  surface  of  the 
retracted  lung.  Fasten  the  flap  in  position  with  sutures  and  properly  applied 
gauze  pads,  so  as  to  insure  good  contact  between  flap  and  lung.  The  remainder 
of  the  cavity  must  be  filled  with  sterile  (not  iodoform)  gauze  and  may  subse- 


DECORTICATION.  257 

quently  be  covered  by  Thiersch's  skin-grafts  or  by  flaps  of  skin.  No  poisonous 
antiseptics  should  be  used  during  the  operation,  and  the  use  of  iodoform  gauze 
is  forbidden,  owing  to  the  great  absorbing  power  of  the  tissues  in  question. 
Karewski  finds  vioform  gauze  as  efficacious  as  iodoform,  and  perfectly  safe 
as  regards  poisoning.  Instead  of  replacing  the  reflected  flap,  Cheyne  and 
Burchard  recommend  packing  the  whole  cavity  with  gauze  for  a  time,  to 
permit  of  free  drainage  and  of  the  formation  of  a  layer  of  granulations  on 
the  deep  surface  of  the  flap. 

As  has  been  said,  the  operation  is  very  severe,  and  the  patients  are  al- 
ways debilitated;  hence  it  is  often  wise  to  refrain  from  completing  the  opera- 
tion at  one  sitting,  but  to  proceed  step  by  step,  e.  g.,  excising  the  ribs 
and  indurated  pleura  from  over  the  lower  part  of  the  empyema,  and  after 
this  procedure  has  been  recovered  from,  to  advance  higher. 

The  incision  described  is  that  of  Schede,  but  an  infinite  variety  of  cuts 
have  been  advocated;  as  Kiimmel  (quoted  by  Karewski)  says,  almost  1/3 
the  letters  of  the  alphabet  have  been  imitated  in  forming  incisions. 

Delorme,  Fowler,  Beck,  and  others  believe  that  the  obstruction  to  oblit- 
eration of  the  empyema  cavity  is  not  so  much  the  rigid  chest  wall  as  the  stiff, 
indurated,  shrunken  visceral  pleura  which  imprisons  and  compresses  the 
lung.  These  surgeons  temporarily  resect  the  thoracic  wall,  free  the  lung 
from  its  prison  by  "decortication,"  and  close  the  chest.  Jordan  and  Krause 
combine  the  method  of  decortication  with  Schede's  operation.  Most  sur- 
geons use  decortication  as  an  aid  to  incision  of  the  thoracic  wall,  but  discard 
the   temporary   resection. 

Pulmonary  Decortication. — George  R.  Fowler  ("Med.  News,"  June 
15,  1901;  "Am.  Year-Book  of  ^Nled.  and  Surg.,"  1902)  performed  this  oper- 
ation in  1893  with  very  gratifying  results.  He  writes:  "An  elliptical-shaped 
incision  was  made  to  include  the  orifice  of  the  sinus,  the  soft  parts  cleared, 
and  about  3  1/2  inches  each  of  the  fifth  and  sixth  ribs  removed  ....  Com- 
mencing at  the  site  of  the  opening  in  the  chest-wall,  the  pleura  was  isolated 
by  blunt  dissection  in  the  direction  of  the  diaphragm  until  the  latter  was 
reached.  It  was  then  peeled  off  the  latter  until  its  limit  towards  the  median 
line  was  reached,  where  it  was  found  to  rest  against  the  displaced  pericar- 
dium, from  which,  after  much  difficulty,  it  was  finally  detached.  This  dis- 
section was  greatly  impeded  by  the  movements  of  the  diaphragm  as  well 
as  those  of  the  heart.  The  dissection  was  completed  by  lifting  the  mass 
and  finally  detaching  it  from  the  lung  above.  Considerable  expansion  of 
the  lung  followed  at  once,  and  in  the  course  of  twenty-eight  days  this  was 
so  far  complete  that  the  normal  vesicular  murmur  was  present  to  the  level 
of  the  seventh  rib  .  .  .  .  Save  for  a  slight  sinking-in  of  the  chest- wall  at 
the  site  of  the  resection  of  the  ribs  there  is  nothing  to  suggest  the  previous 
existence  of  an  empyema." 

Fowler   formulates   the   following   conclusions: 

"i.  Decortication  of  the  lung  is  an  operation  adapted  to  all  cases  of  old 
J7 


258  OPERATIONS  ON  THE  CHEST. 

empyema  in  which  extensive  and  preoperatively  discoverable  tuberculous 
lesions  of  the  lungs  are  not  present,  and  in  which  the  patient's  condition  will 
permit  of  a  major  operation. 

"2.  It  may  be  advantageously  substituted  for  Estlander's  operation    .    .    . 

"3.  It  should  replace  Schede's  operation  in  all  cases. 

"4.  The  method  by  extirpation  of  the  diseased  portion  of  the  pleural 
membrane,  including  the  visceral,  cortical,  and  diaphragmatic  portions, 
is  the  operation  of  choice. 

"5.  Failing  this,  visceral  pleurectomy  should  be  selected. 

"6.  Pleurotomy,  with  simple  detachment  of  the  visceral  layer  of  the 
diseased  pleural  membrane,  gives  sufficiently  good  results  to  warrant  the 
surgeon  in  resorting  to  this  procedure  in  cases  in  which  the  condition  of 
the  patient  will  not  permit  of  the  application  of  the  other  and  more  desirable 
methods. 

"7.  Whatever  operative  method  is  adopted,  as  complete  access  to  the 
cavity  of  the  chest  as  possible  should  be  obtained,  and  rapid  closure  of  the 
opening  in  the  chest- wail  afterwards  secured,  since  the  complete  re-expan- 
sion of  the  lung  must  depend  largely  upon  the  normal  respiratory  movements. 

"8.  Pulmonary  or  respiratory  exercises  should  not  be  neglected  in  the 
after-treatment   .    .    .    . " 

Delorme  in  1894  performed  an  operation  very  similar  to  that  of  Fowler 
("Amer.  Year-Book  of  Med.  and  Surg.,"  1902),  and  did  it  successfully  un- 
der spinal  cocainization.  Out  of  twenty-nine  cases  of  decortication  by  the 
Fowler  method  the  functional  results  were  eleven  cured,  six  improved,  nine 
unimproved,  three  died;  as  regards  the  cure  of  the  empyema,  seventeen  were 
cured,  nine  unimproved,  three  died. 

Delorme  has  devised  a  method  of  temporary  resection  of  the  chest-wall, 
by  forming  and  reflecting  a  flap  consisting  of  the  whole  chest-wall;  this  being 
done,  he  decorticates  the  lung,  cleans  the  empyema  cavity,  and  replaces  the 
flap  of  chest-wall,  providing  of  course  for  drainage.  This  operation  has 
not  found  much  favor. 

Roux  in  operating  finds  that  a  long  incision  through  the  indurated  vis- 
ceral pleura  answers  the  same  purpose  as  decortication. 

Kocher  in  his  work  on  empyema  is  an  opportunist;  as  the  operation 
proceeds  he  finds  out  what  has  to  be  done  and  does  it.  If  a  fistula  is  present, 
he  excises  sufficient  of  one  or  two  ribs  in  its  location  to  permit  of  thorough 
exploration;  if  no  fistula  is  present  or  if  it  is  so  situated  that  exploration  from 
its  site  would  be  imperfect,  he  finds,  by  exploratory  puncture,  the  lowest 
part  of  the  empyema,  and  there  resects  one  or  two  ribs.  Guided  by  the  finger 
in  the  cavity  he  enlarges  his  original  incision  in  the  soft  parts  backwards 
and  upwards  between  the  spine  and  the  scapula  to  the  uttermost  limits  of 
the  eml)yema.  Step  by  step  he  divides  the  ribs  and  intercostal  muscles  in 
the  line  of  the  skin-incision.  If  the  empyema  extends  to  the  first  rib,  then 
the  first  rib  must  be  divided.     From  the  anterior  end  of  the  original  incision, 


PHTHISIS.  259 

guided  by  the  necessities  of  the  case,  the  wound  is  enlarged  forwards  and 
upwards  and  the  corresponding  portions  of  the  ribs  or  costal  cartilages  divided. 
This  flap,  consisting  of  the  whole  thickness  of  the  thoracic  wall,  can  be  re- 
flected upwards  sufficiently  to  expose  the  position  of  the  lung  and  the  condi- 
tion of  the  visceral  pleura.  If  an  incision  through  the  visceral  pleura  demon- 
strates that  the  lung  can  expand,  Kocher  proceeds  to  pulmonary  decortica- 
tion until  the  lung  expands  sufficiently  to  fill  the  cavity.  If  the  lung  does 
not  expand  or  does  so  only  partially,  he  now  proceeds  to  subperiosteal  resec- 
tion of  the  ribs,  attacking  them  from  the  deep  surface  of  the  flap  (Depage's 
method).  To  obtain  proper  mobility  in  the  flap  it  may  even  be  necessary 
to  excise  the  first  rib — no  easy  matter  because  of  the  subclavian  vein.  If  the 
indurated  costal  pleura  prevents  the  application  of  the  flap  to  the  shrunken 
lung,  then  the  oS'ending  pleura  must  be  excised.  If,  after  incision  and 
decortication  of  the  visceral  pleura,  the  lung  expands  sufficiently  to  obliter- 
ate the  empyema  cavity,  Kocher  follows  Delorme  in  replacing  the  osteoplastic 
flap,  but  provides  for  drainage  by  excising  a  small  segment  of  rib  through 
a  special  incision. 

The  after-treatment  of  cases  in  which  any  of  the  methods  of  thoraco- 
plasty has  been  used  is  prolonged;  often  a  year  or  more  elapses  before  a  cure 
is  obtained,  and  during  this  time  several  subsidiary  and  plastic  operations 
may  be  necessary.  One  would  naturally  expect  that  ultimately  great  deform- 
ity, especially  scoliosis,  would  be  present,  and  that  the  lung  deprived  of  its 
thoracic  wall  would  be  useless.  This  is,  however,  not  the  case.  Wonderfully 
little  deformity  persists;  the  lung  expands  and  becomes  a  useful  organ.  In 
many  cases  there  is  a  very  evident  reformation  of  ribs.  As  Karewski  says, 
we  must  not  be  too  sparing  in  removing  large  portions  of  ribs,  especially  in 
children,  when  this  is  demanded,  as  the  lungs  can  still  expand,  and  thus 
thoracic  deformity  may  be  avoided  or  reduced  to  a  minimum. 

Resection  of  the  thoracic  wall  does  not  per  se  cause  much  deformity.  The 
deformity  depends  on  the  amount  of  intrathoracic  changes.  It  is  not  the 
removal  of  the  chest-wall  but  the  shrinking  of  its  contents  which  is  to  blame 
(Th.   Gluck.  Archiv  fiir  klin.   Chir.,"  Ixxxiii,  587). 

When  empyema  affects  both  pleural  cavities  the  following  operations 
may  be  performed:  (i)  Double  aspiration;  (2)  incision  on  one  side,  aspira- 
tion on  the  other;  (3)  incision  on  both  sides;  (4)  resection  and  aspiration;  (5) 
resection  and  incision;  (6)  resection  on  both  sides  (resection  may  include 
decortication).  Hellin  ("Berliner  klin.  Woch.,"  1905,  No.  45)  recommends 
the  operation  of  incision  with  drainage  in  double  empyema;  operation  to  be 
limited  to  one  side  at  a  time,  and  aspiration  to  be  done  one  or  two  days  prior 
to  the  incision.     Local  anaesthesia  is  usually  sufficient. 

OPERATIVE  TREATMENT  OF  PHTHISIS  PULMONALIS. 

Excision  of  portions  of  the  lung  for  tuberculosis  has  been  of  little  or  no 
value.     The  same  is  true  regarding  the  treatment  of  phthisical  cavities  by 


26o 


OPERATIONS    ON    THE    CHEST. 


means  of  aspiration  and  of  injections.  When  nature  cures  tuberculosis 
she  does  so  by  converting  the  granulation  tissue  into  mature  scar  tissue. 
If  a  phthisical  cavity  becomes  obliterated,  it  is  by  the  contraction  of  scar 
tissue,  and  this  contraction  causes  a  deformity  or  sinking  in  of  the  chest-wall. 
Murphy  and  others  endeavored  to  obtain  collapse  of  the  lung  and  obliter- 
ation of  the  phthisical  cavities  by  the  production  of  a  sort  of  artificial  pneu- 
mothorax. (Murphy  filled  the  pleura  on  the  affected  side  with  nitrogen  gas.) 
These  attempts  gave  no  very  permanent  results.  Numerous  attempts  have 
been  made  to  permit  atmospheric  pressure  to  obliterate  phthisical  cavities 
by  the  resection  of  the  bony  chest-wall  directly  over  the  cavities.  These 
attempts  have  failed  because  of  insufficient  sinking  in  of  the  chest-wall. 


Fig.  332. — (Friedrich.) 


Friedrich  (in  conjunction  with  his  colleague  Brauer)  recognizing  the  dan- 
gers of  pneumothorax,  and  that  adhesions  between  the  lung  and  the  chest- 
wall  can  easily  prevent  sufficient  collapse  of  the  lung  when  gases  are  put  into 
the  pleura,  came  to  the  conclusion  that  a  very  free  removal  of  the  rigid  chest- 
wall  without  opening  the  pleura  would  be  of  value.  This  procedure  he  has 
carried  out  and  has  named  pneumolysis.  The  cases  in  which  pneumolysis 
is  justifiable  must  present  the  following  conditions:  (a)  The  disease  must 
be  mostly  confined  to  one  lung;  the  opposite  lung  can  rarely  be  intact,  (b) 
The  disease  musi  be  progressing  in  spite  of  proper  and  thorough  medical  and 
climatic  treatment.     (Friedrich's   cases   were   sent   from   sanatoriums   where 


PNEUMOLYSIS. 


261 


they  had  been  under  observation  for  several  months  or  years.)  (c)  The 
general  condition  must  be  fair  in  order  to  withstand   the   severe  operation. 

In  most  of  the  cases  operated  on  by  Friedrich  from  120  to  200  c.c.  of  spu- 
tum containing  bacilli  was  expectorated  in  24  hours,  and  fever  was  present 
up   to   the   time   of   operation. 

Preparatory  Treatment. — For  three  days  administer  digitalis  hypoder- 
matically.  Attend  to  the  bowels  without  weakening  the  patient.  '  Give 
nutritious,  easily  digested  food.  In  adults  (not  in  the  young)  administer 
morphine  an  hour  before  operation. 


Fig.  333. — {Friedrich.) 


The  Operation. — Ancesthesia. — In  adults  inject  as  much  as  500  c.c.  or 
more  of  Schleich's  No.  2  solution  but  minus  morphine  and  plus  8  drops  of 
adrenalin  to  the  100  c.c.  This  injection  is  made  along  the  line  of  incision 
and  under  the  flap  to  be  elevated.  Most  of  the  solution  escapes  during  the 
operation.  Sometimes  Friedrich  lightly  freezes  the  skin  along  the  line  of 
incision  with  a  spray  of  ethyl  chloride.  After  the  skin  and  muscle  flap  is 
reflected  chloroform  is  administered. 

In  the  young  (under  sixteen  years)  chloroform  is  used  from  the  begin- 
ning in  von  Braun's  apparatus.  In  a  case  seen  by  the  author  only  seven 
grams  of  chloroform  sufiiced.) 

Lay  the  patient  on  his  sound  side.  Let  an  assistant  hold  the  arm  (well 
protected)  and  be  ready  to  elevate  it  over  the  patient's  head. 


262 


OPERATIONS    ON    THE    CHEST. 


Step  I.— Make  the  huge  U-shaped  incision  shown  in  Figs.  332  and  2)2)i- 
In  the  female  the  breast  is  avoided.     (Fig.   334.) 

Step  2. — Reflect  the  flap  outlined.  The  flap  contains  skin,  all  the  mus- 
cles down  to  the  ribs,  and  the  scapula.  Obtain  free  access  to  every  rib  from 
the  tenth  up  to  and  including  the  second. 

Step  3. — If  local  ancesthesia  has  been  used,  administer  chloroform  now. 

Step  4. — Beginning  at  the  tenth  rib  proceed  as  follows:  (o)  Reflect 
the   periosteum    upwards   and    downwards   from    the    whole   e.xternal    surface 


Fig.  334. — {Friedrich.y 

of  the  rib.  {b)  Near  the  middle  of  the  rib  separate  the  periosteum  from 
the  lower  edge  of  the  bone  (for  this  purpose  a  nick  with  a  knife  is  usually 
necessary).  With  gauze,  linger  and  elevator  carefully  separate  the  perios- 
teum plus  the  intercostal  vessels  from  the  groove  under  the  rib.  Complete 
the  separation  of  the  periosteum  from  the  deep  surface  of  the  rib,  and  pass 
Friedrich's  curved  elevator  completely  around  the  rib.  The  curved  elevator 
being  round  the  rib,  pull  it  (the  elevator)  with  force  back  to  or  beyond  the 


PNEUMOLYSIS.  263 

angle  of  the  rib  and  forwards  to  the  junction  of  the  rib  and  costal  cartilage. 
Divide  the  rib  at  its  junction  with  the  cartilage  by  means  of  a  costotome. 
Seize  the  end  of  the  rib  and  pull  it  outwards.  Pass  a  finger  along  the  visceral 
side  of  the  rib  to  its  head,  to  protect  the  pleura.  Twist  the  rib  until  it 
comes  away.  (Sometimes  the  head  of  the  rib  is  torn  from  its  connections; 
sometimes  the  neck  of  the  bone  is  fractured.) 

Step  5. — Repeat  Step  4  on  each  rib  until  the  second  is  removed. 


Fig.  335. — (Friedrich.) 

Step  6. — With  gauze  and  sharp  dissection  remove  the  intercostal  muscles 
from  the  pleura.  The  twisting  away  of  the  ribs  obliterates  the  intercostal 
arteries. 

(Duration  of  operation  up  to  end  of  Step  6  was  twenty-five  minutes  in 
the   case   seen    by   the   author.) 

Step  7. — Apply  ligatures.  Replace  the  flap  and  unite  the  divided  muscles 
with  catgut.  Place  a  drain  along  the  deep  wound  corresponding  to  the  heads 
of   the   ribs.     Close   the   skin   wound.     Apply   abundant   dressings.     Opera- 


264  OPERATIONS    ON   THE   CHEST. 

tion  on  the  right  side  is  much  more  dangerous  than  on  the  left  because  of 
cardiac  dislocation. 

After-treatment. — Administer  hypodermatically  i  c.c.  camphor  oil  forty 
per  cent.  (40  per  cent.)  every  hour  by  day  and  every  two  hours  by  night.  Give 
digitalis  freely.  Each  night  inject  i  1/2  L.  salt  solution  in  the  inguinal  re- 
gion. The  salt  solution  has  a  most  favorable  influence  on  respiration.  Ad- 
minister oxygen  frequently. 

Of  eight  cases  only  two  died  and  these  had  advanced  secondary  lesions 
elsewhere. 

Of  course,  after  recovery,  medical  and  climatic  treatment  must  be  con- 
tinued. 

Figs.  334  and  335  show  the  extent  of  compensatory  emphysema  estab- 
lished in  the  sound  lung  and  the  great  displacement  of  the  heart. 

In  a  few  weeks  the  sputum  has  diminished  from  150  or  200  c.c.  to  20  or 
even  5  c.c.  and  the  patients  have  lost  their  fever  and  gained  in  weight.  The 
operation  is  suh  judice  but  seems  to  be  of  considerable  promise. 

FREUND'S  OPERATION  FOR  ALVEOLAR  PULMONARY  EMPHY- 
SEMA AND  APICAL  PHTHISIS. 

In  1859  Freund  demonstrated  two  important  conditions  of  the  thorax 
which  were  primary  (direct  or  indirect)  causes  of  pulmonary  disease. 

1.  Impeded  development  of  the  first  costal  cartilage  caused  stenosis  of 
the  upper  aperture  of  the  thorax  and  this  symmetrical  or  asymmetrical  sten- 
osis influenced  the  structure  and  function  of  the  apex  of  the  lung  so  as  to 
render  it  susceptible  to  tuberculosis.  If  pseudarthrosis  developed  in  this 
stenosed  and  immobile  costal  ring  and  permitted  motion  then  a  natural  cure 
of  the  apical  tuberculosis  supervened.  For  fifty  years  Freund  urged  oper- 
ation to  produce  such  pseudarthrosis  and  for  fifty  years  his  colleagues  shook 
their  heads  to  his  pleadings. 

2.  Degeneration  of  the  costal  cartilages  causing  their  enlargement  and 
immobility  in  a  position  of  inspiration  (previously  observed  by  Dupuytren) 
caused  a  widening  of  the  lower  thoracic  opening  and  a  flattening  and  atrophy 
of  the  diaphragm. 

The  resulting  permanent  dilatation  of  the  thorax  led  to  permanent  disten- 
tion of  the  lung,  i.  e.,  to  alveolar  emphysema. 

Freund  formulated  the  following  indications  for  operation:  When  sten- 
osis of  the  upper  aperture  is  demonstrated  and  there  is  repeated  catarrhal 
trouble  in  the  apex  of  the  lung,  operation  is  proper  as  a  prophylactic  measure; 
when  under  similar  conditions  an  apical  tuberculosis  is  present  but  does 
not  extend  below  the  second  rib,  then  a  curative  operation  is  indicated. 

An  operation  is  indicated  in  the  early  stages  or  in  fully  developed  alveo- 
lar emphysema  before  the  occurrence  of  secondary  affections  with  atrophy 
and  great  rarefication  of  the  lung  tissue  and  of  atrophy  of  the  diaphragm, 


freund's  operation. 


265 


when  rigid  dilatation  of  the  chest-wall  is  demonstrable.  ("Archiv  fur  klin. 
Chir.,"   xcii,   974). 

Von  Hansemann  ("Archiv  flir  klin.  Chir.,"  xcii  993)  considers  Freund's 
operation  very  advisable  in  typical  cases  of  apical  phthisis  where  there  is 
stenosis  of  the  upper  opening  of  the  thorax  and  where  the  disease  does  not 
extend  lower  than   the   second  or  third   rib. 

Mohr  emphasizes  the  fact  that  Freund's  operation  in  alveolar  emphysema 
is  directed  not  against  the  pulmonary  dilatation  but  against  the  dilated  and 
rigid  thorax  which  causes  the  emphysema.  Operation  must  be  followed 
by  proper  gymnastic  exercises  so  that  the  muscles  used  in  respiration  receive 
proper  education  and  training.  Before  deciding  on  operation  it  is  impor- 
tant to  study  the  condition  of  the  heart,  etc.,  lest  relief  of  the  thoracic  rigidity 


might  affect  disastrously  cardiac  compensation.  Mohr's  experience  with 
Freund's  operation  is  considerable  and  he  has  been  much  impressed  with 
its  value. 

Freund's  suggestion  has  been  carried  out  successfully  by  O.  Hildebrand, 
Bramann  and  Haasler,  Passler  and  Seidel,  Goodman  and  Wachsmann, 
Friedrich,  etc. 

The  value  of  Freund's  operation  was  substantiated  by  the  reports  of  many 
operators  at  the  German  Surgical  Congress  of  1910. 

The  operation  may  be  done  under  local  or  general  anaesthesia.  Cardiac 
insuflBciency,  asthma,  chronic  bronchitis  and  albuminuria  according  to 
Friedrich  are  not  necessarily  contraindications  to  operation. 


266  OPERATIONS    ON    THE    CHEST. 

The  Operation. 

Step  I. — Make  the  somewhat  curved  incision  A  B  (Fig.  336).  Expose 
the  ribs  and  costal  cartilages  for  i   1/2  to  2  1/2  inches  at  their  junction. 

Step  2. — Excise  about  i  1/2  to  2  1/2  inches  of  the  ribs  and  cartilages  at 
their  junction.     This  is  done  to  the   2d,  3d,  4th,  5th  and  6th  ribs. 

Carefully  remove  the  periosteum  and  perichondrium  corresponding  to 
the  excised  portions  of  rib.     This  is  done  to  prevent  reformation  of  rib. 

Axhausen  ("  Zentralblatt  fiir  Chir.,"  May  14,  1910)  notes  the  difficulty 
of  excising  the  periosteum  and  perichondrium  left  after  removal  of  the  ribs 
and  suggests  overcoming  this  difficulty  by  applying  the  thermocautery  to  the 
membrane  instead  of  endeavoring  to  excise  it. 

On  purely  theoretical  grounds  it  seems  to  the  author  that  it  would  be  wise 
to  reflect  a  flap  of  periosteum,  base  outwards,  from  the  anterior  surface  of  the 
ribs,  corresponding  to  the  segment  to  be  removed  and  after  removal  of  the 
segment  of  rib  to  carefully  cover  the  cut  end  of  the  rib  with  the  periosteal  flap. 

In  one  of  Friedrich's  cases  (local  anaesthesia)  the  patient  drew  attention 
to  the  immediate  relief  obtained  in  his  diaphragmatic  respiration  as  soon 
as  a  rib  was  divided. 

OPERATIVE  TREATMENT  OF  COSTAL  TUBERCULOUS  OSTEITIS 
AND  OF  THE  RESULTING  ABSCESSES. 

The  most  common  and  least  efficacious  treatment  of  the  above  affection 
is  incision,  thorough  scraping  with  a  sharp  spoon,  and  iodoformization.  This 
treatment  is  often  insufficient,  and  when  we  remember  that  the  excision  of 
a  segment  of  a  rib  is  easy  and  harmless,  then  we  can  have  little  hesitation  in 
adopting  more  radical  and  effectual  methods. 

Let  it  be  assumed  that  we  have  to  treat  an  unopened  abscess,  not  adher- 
ent to  the  skin,  originating  from  a  tuberculous  focus  in  a  rib.  Cheyne  rec- 
ommends an  operation  on  the  following  lines:  Make  a  vertical  or  oblique 
incision  through  the  skin  over  the  abscess.  The  incision  ought  to  extend 
at  either  end  beyond  the  abscess  itself.  Retract  the  edges  of  the  wound  and 
dissect  back  the  skin  from  over  the  abscess  until  the  whole  swelling  is  freely 
exposed.  Instead  of  the  above,  a  curved  incision  may  be  used  and  a  more 
or  less  U-shaped  flap  of  skin  elevated  to  expose  the  swelling.  If  possible, 
without  rupturing  the  abscess,  dissect  it  free  from  its  surroundings  except  where 
it  is  attached  to  the  offending  rib.  Expose  the  offending  rib  or  ribs  at  each 
side  of  the  abscess  and  subperiosteally  divide  them  in  such  a  manner  that 
the  whole  mass,  abscess  cavity  and  rib,  is  remved  en  masse,  leaving  the  pos- 
terior layer  of  periosteum  in  situ.  On  the  normal  cadaver  this  operation 
is  difficult  to  do  without  puncturing  the  pleura,  but  in  cases  in  which  it  is  in- 
dicated, although  caution  must  be  exercised  to  avoid  this  accident,  the  ac- 
cident is  unlikely  to  happen,  as  the  disease  has  caused  thickening  of  the  tis- 
sues.    After  removal  of  the  abscess  and  segment  of  rib,  examine  carefully 


CHEST    WALL.  267 

the  remaining  periosteum;  if  it  is  diseased,  curette  and  swab  it  with  liquid 
carbolic  acid  (neutralizing  the  acid  by  wiping  with  alcohol)  or  cautiously 
excise  the  diseased  tissue.  Attend  to  hemostasis  and  close  the  wound,  after 
having  provided  for  drainage.  If  it  is  impossible  to  excise  the  abscess  intact, 
evacuate  it  either  by  incision  and  careful  cleansing  or  by  aspiration  or  punc- 
ture. If  aspiration  or  puncture  has  been  employed,  close  the  puncture  in 
the  abscess  wall  with  a  clamp  or  a  purse-string  suture  before  continuing  the 
dissection.  The  same  principles  of  treatment  must  be  applied  in  cases  of 
osseous  disease  with  sinus  formation. 

When  an  infective  disease,  such  as  tuberculosis  or  typhoid,  attacks  one 
or  more  of  the  costal  cartilages,  repeated  operations  may  be  necessary  before 
recovery  takes  place.  Roux  considered  such  cases  almost  incurable  until 
he  attacked  them  as  follows:  Through  healthy  tissue  make  an  incision  all 
around  the  focus  of  disease.  Divide  the  skin,  muscles,  cartilage,  and,  if 
necessary,  the  bone.  When  this  cut  has  become  sclerosed,  proceed  to  excise 
the  disease.  The  wall  of  sclerotic  tissue  provided  by  the  primary  operation 
prevents  spread  of  the  disease  in  the  now  resistant  cartilage  ("Rev.  de  Chir.," 
Nov.,    1904). 

EXCISION  OF  TUMORS  OF  THE  CHEST- WALL  AND  OF  THE 

PLEURA. 

Malignant  tumors  of  the  thoracic  wall  are  seldom  attacked  unless — e.g., 
in  the  course  of  an  amputation  of  the  breast — a  tumor  is  accidentally  found 
to  be  attached  to  the  thorax,  a  state  of  affairs  not  known  before  the  operation 
was  begun.  Parham  has  successfully  removed  a  sarcoma  of  the  chest-wall. 
Rixford  ("Annals  of  Surg.,"  1906,  No.  i)  has  removed  several  carcinomata 
affecting  the  chest-wall.  Deruginsky  ("Annals  of  Surg.,"  1906,  No.  5) 
resected  a  portion  of  the  chest-wall  and  the  diaphragm  for  primary  sarcoma 
of  the  pleura;  the  patient  survived  long  enough  to  die  from  recurrence.  Os- 
teomata  of  the  ribs  ought,  other  things  being  favorable,  always  to  be  re- 
moved, because  of  the  disastrous  effects  of  their  growth.  The  technic  of  the 
operation  is  very  similar  to  that  for  the  removal  of  tuberculous  foci,  and  is 
along    the   following   lines: 

1.  Make  an  incision  all  around  the  tumor,  preserving  as  much  skin  as 
possible  without  cutting  too  near  the  disease. 

2.  Free  the  tumor  from  its  surroundings,  sacrificing  all  muscular  tissue 
attached    to   it. 

3.  Subperiosteally  divide  all  the  ribs  to  which  the  tumor  is  adherent. 

4.  Note  if  the  pleura  is  adherent  to  the  tumor;  if  it  is,  then  excise  the 
adherent  portions  along  with  the  tumor.  Endeavor  to  avoid  the  sudden 
entrance  of  air  into  the  pleura.  Let  the  primary  opening  into  the  pleura  be 
small,  so  that  the  air  enters  slowly;  with  a  moist  pad  of  gauze  close  the  opening 
at  intervals  so  that  the  conditions  of  internal  and  external  pressure  may  have 


268  OPERATIONS    ON    THE    CHEST. 

time  to  adjust  themselves.  As  the  pleural  wound  is  enlarged,  progressively 
pack  gauze  (sterile)  into  the  pleural  cavity.  The  gauze  packs  shut  off  the 
rest  of  the  cavity  from  the  field  of  operation.  Before  the  pleura  is  opened, 
warn  the  anaesthetist  to  let  the  patient  come  out  of  deep  anaesthesia.  Cough- 
ing on  the  part  of  the  patient  is  now  desirable,  as  the  violent  distention  of 
the  lung  helps  to  guard  against  dangerous  pneumothorax.  When  the  pack- 
ing of  gauze  has  been  thoroughly  done,  violent  disturbances  of  respiration 
do  not  continue  long.  After  the  tumor  has  been  removed,  the  gauze  must 
be  withdrawn  and  the  lung,  which  is  generally  "coughed  into"  the  wound, 
is  caught  and  fixed  to  the  thorax  with  a  few  stitches.  This  pneumopexy  is 
of  special  importance  when  part  of  the  lung  demands  removal. 

When  a  segment  of  lung  is  affected  by  the  tumor,  it,  of  course,  is  adher- 
ent to  it,  and  thus  it  is  easy  to  apply  sutures  all  around  the  diseased  area. 
Dollinger  advises  that  pneumothorax  be  slowly  produced  the  day  prior  to 
operation.  Delageniere,  after  taking  similar  precautions,  has  operated 
for  two  hours  in  the  open  thorax  without  ill  effect.  The  safety  of  slowly 
produced  pneumothorax  is  evidenced  by  J.  B.  Murphy's  work  on  phthisis 
pulmonalis.  One  of  the  many  methods  of  operating  under  differential  pres- 
sure may  be  adopted  with  good  effect.  After  removal  of  all  the  disease, 
even  perhaps  of  part  of  the  diaphragm,  close  the  wound  with  sutures,  pro- 
viding efiicient  drainage. 

If  so  much  skin  has  been  removed  that  complete  closure  is  impossible, 
and  if  there  has  been  no  suturing  of  the  lung  to  the  thoracic  wall  (pneu- 
mopexy), part  at  least  of  the  gauze  packing  must  be  left  in  place  until  ad- 
hesions form.  In  every  case  the  dressings  must  be  liberal,  air-tight,  and 
left  undisturbed  as  long  as  possible.  Emmet  Rixford  recommends  closure 
of  the  wound,  under  the  above  circumstances,  by  means  of  a  flap  taken  from 
the  abdomen  or  from  the  chest-wall  of  the  opposite  side.  The  lung  soon 
expands,  and  air  left  in  the  pleura  rapidly  disappears.  (The  preceding  de- 
scription of  excision  of  tumors  is  largely  taken  from  Karewski's  admirable 
clinical  lectures.)  Rixford's  paper  on  "Excision  of  Portions  of  the  Chest-wall 
for  Malignant  Tumors"  ("Annals  of  Surgery,"  Jan.,  1906)  substantiates  in 
almost  every  particular  the  advice  given  above. 

Pneumotomy. — Incision  of  the  lung  is  demanded  to  provide  for  drain- 
age in  cases  of  pulmonary  gangrene,  abscess  (whether  tuberculous  or 
pyogenic  in  origin),  and  large  bronchiectatic  cavities;  also  for  the  treat- 
ment of  echinococcic  cysts. 

Operation  is  clearly  indicated  when  the  gangrenous  area  or  the  abscess 
is  limited  in  extent,  not  multiple  and  is  fairly  accessible.  It  is  usually  con- 
sidered improper  to  operate  when  the  affected  lung  is  widely  diseased — e.  g., 
when  there  are  large  bronchiectacic  cavities  requiring  drainage  in  both  upper 
and  lower  lobes,  but  Th.  Gluck's  experience  shows  that  such  may  properly 
be  attacked.  The  mortality  of  pulmonary  gangrene  treated  non-surgically 
is  80  per  cent.;  treated  surgically,  29  per  cent.  (McArthur). 


ABSCESS   LUNG.  269 

G.  Picot  considers  the  mortality  more  than  75  per  cent,  without  opera- 
tion. When  operation  is  performed  early,  some  statistics  show  a  mortality 
of  but  17  per  cent,  but  operation  should  only  be  undertaken  where  there 
is  a  single,  circumscribed  focus  and  the  patient  has  good  resisting  power. 
Picot  considers  "radiography  preceded  by  radioscopy  "  to  be  the  most  valuable 
method  of  diagnosis  as  exploratory  puncture  is  fallacious  and  dangerous 
while  ordinary  clinical  tests  have  led  to  innumerable  errors  in  localization. 

The  abscess  is  carefully  localized  by  the  usual  methods  of  physical  diagno- 
sis. During  the  first  week  of  the  existence  of  gangrene  the  X-ray  will  show 
a  shadow,  but  after  this  time  putrefaction  leads  to  cavity  formation  and  the 
rays  show  a  light  area.  After  cleaning  the  skin  over  the  site  of  the  lesion  it 
is  commonly  advised  to  explore  in  the  following  manner:  The  long  and 
delicate  needle  of  an  exploring  syringe  is  pushed  in  the  direction  in  which 
the  pus  is  believed  to  exist.  The  needle  ought  to  be  attached  to  the  syringe 
by  means  of  rubber  tubing  which  has  been  divided  and  reunited  by  the  in- 
terposition of  a  small  glass  bulb  or  tube.  When  the  point  of  the  needle  has 
penetrated  the  lung  to  the  suspected  area,  slight  suction  is  made  with  the 
syringe.  If  any  pus  is  present,  it  will  be  noticed  in  the  glass  placed  in  the 
tubing.  If  no  pus  is  found,  make  the  needle  penetrate  more  deeply  and 
repeat  the  suction.  After  every  change  in  the  position  of  the  needle  make 
the  suction  test  with  the  syringe.  When  the  piston  of  the  syringe  has  been 
pulled  out  to  its  full  extent,  clamp  the  rubber  tube,  detach  the  syringe,  push 
the  piston  down,  attach  the  syringe  to  the  tube,  remove  the  clamp,  and  pro- 
ceed as  before.  It  may  be  necessary  to  push  the  needle  in  various  directions 
before  the  pus  is  found.  Having  found  the  abscess  by  the  above  means, 
leave  the  needle  in  situ  and  proceed  to  expose  the  abscess. 

Most  experienced  surgeons  are  afraid  of  infecting  the  pleura  if  they  use 
the  exploring  needle  in  the  above  manner.  Expose  the  affected  area  by 
subperiosteally  removing  a  segment  of  one  or  more  ribs,  palpate  the  unin- 
jured pleura,  noting  if  motion  and  friction  are  absent  and  if  it  is  grayish- 
yellow  in  color  or  infiltrated  (signs  of  adliesions).  McArthur  advises  that 
a  fine  exploring  needle  be  inserted  for  i  cm.  (3/8  inch)  or  less;  if  no  adhe- 
sions are  present  the  moving  lung  will  cause  the  needle  to  rock;  if  adhe- 
sions are  present  the  lung  cannot  slide  on  the  parietal  pleura,  hence  the  needle 
will  not  rock.  Note  that  this  needle  is  not  being  used  to  explore  for  pus, 
but  for  adhesions.  In  the  absence  of  adhesions  it  is  advised  never  to  use 
the  needle  to  hunt  for  pus,  because  of  the  danger  of  infecting  the  pleura.  If 
adhesions  are  present  and  palpation  shows  that  solid — /.  e.,  diseased — lung 
is  opposite  the  wound,  either  search  for  the  pus  with  an  aspirating  needle 
(if  pus  is  found  leave  the  needle  in  situ  until  a  free  opening  is  made  into  the 
abscess)  or  at  once  penetrate  the  diseased  area  with  a  closed  sinus  forceps 
or  with  a  Paquelin  cautery  heated  to  a  dull  red  color.  When  ihe  Paquclin 
cautery  enters  the  cavity  not  only  will  pus  flow,  but  smoke  will  be  inhaled 
and  exhaled.     The  principal  advantage  gained  from  the  use  of  the  cautery 


270  OPERATIONS    ON    THE    CHEST. 

is  that  the  walls  of  the  channel  made  by  it  are  sealed  against  absorption  of 
the  pus  coming  from  the  opened  abscess.  When  the  cavity  has  been  pene- 
trated, pass  in  the  finger,  explore  and  open  secondary  cavities,  gently  remove 
with  the  finger  and  gauze  loose  sloughs  and  debris.  Do  not  break  down 
any  bands  felt  traversing  the  cavity,  such  may  be  blood-vessels.  Do  not 
douche  the  cavity:  douching  is  well  calculated  to  spread  infection  to  other 
parts  of  the  lung  or  to  drown  the  patient.  Do  not  use  peroxide  of  hydrogen, 
the  explosive  frothing  of  this  drug  has  all  the  evils  of  the  douche.  Intro- 
duce a  loose  gauze  pack.  If  iodoform  is  used  in  the  gauze  let  it  be  in  feeble 
quantity,  as  it  is  liable  to  be  rapidly  absorbed  and  cause  poisoning.  Instead 
of  gauze  a  split  rubber  tube — preferably  covered  with  gauze — may  be  used. 
The  tube  unless  soft  or  protected  may  cause  pressure  necrosis  and  hemor- 
rhage.    A  cigarette  drain  is  efficient  and  safe. 

If  when  the  pleura  is  exposed  the  adhesions  do  not  appear  so  strong  as 
to  be  above  suspicion,  reinforce  them  by  a  few  catgut  stitches  uniting  the  pa- 
rietal and  visceral  pleura  around  the  operative  area.  ,  A  patient  of  L.  L.  Mc- 
Arthur  seemed  to  be  progressing  favorably  when  he  began  to  cough  severely, 
ruptured  the  pleural  adhesions,  infected  the  healthy  pleura  and  died  from 
the  infection. 

Adhesions  being  present,  "how  shall  we  look  for  the  diseased  area  in 
the  lung  if  it  is  not  immediately  before  us  ?  Circumscribed  gangrene  in  the 
lung  is  always  surrounded  by  a  zone  of  infiltrated  inflammatory  tissue — 
nature's  barrier  to  the  progress  of  the  disease — so  with  the  knife  and  finger 
we  will  explore  any  indurated  area  that  may  be  present.  If  this  fails  to  re- 
veal the  disease  we  will  use  the  exploring  or  aspirating  needle,  and,  by  passing 
it  in  various  directions  in  the  lung,  judge  from  the  feeling  imparted  to  the 
fingers  the  character  of  the  tissue  the  point  is  traversing,  and  also  from  the 
discharges  the  needle  may  bring  away.  If  this  gives  us  negative  results  it 
is  best  to  discontinue  any  further  search,  and  complete  the  operation  by  leav- 
ing a  drainage-tube  in  the  incision  in  the  lung.  All  hope  of  evacuating  the 
septic  material  need  not  yet  be  abandon-ed,  for  several  cases  have  been  re- 
ported where  the  pus  has  found  its  way  to  the  drainage-tube  within  a  few 
days,  and  the  patient  has  ultimately  made  a  good  recovery." 

If,  after  subperiosteal  resection  of  the  ribs,  the  pleura  is  found  to  be  non- 
adherent, adhesions  must  be  provided,  otherwise  as  soon  as  the  pleural  cav- 
ity is  opened  a  dangerous  condition  of  pneumothorax  obtains.  The  for- 
mation of  adhesions  may  be  stimulated  by  the  application  of  irritants,  such 
as  chloride  of  zinc,  to  the  outer  surface  of  the  unopened  parietal  pleura.  This 
is  rather  a  blind  method  of  reaching  the  goal.  Most  surgeons  proceed  some- 
what as  follows:  A  fully  curved  needle,  armed  with  a  thick  silk  or  catgut 
suture,  is  passed  through  the  unopened  pleura,  made  to  pick  up  as  large  a 
bite  of  the  lung  and  visceral  pleura  as  is  possible,  and  brought  out  again 
through  the  parietal  pleura.  Much  gentleness  must  be  exercised  in  tying 
the  sutures  as  the  pulmonary  tissue  is  friable.     From  two  to  four  sutures  will 


PNEUMECTOMY.  27 1 

generally  be  found  ample  to  secure  apposition  of  the  two  pleural  layers.  The 
parietal  pleura  is  weak,  therefore  the  sutures  should  catch  other  tissues  as 
well.  The  sutures  may  be  made  to  penetrate  a  large  gauze  pad  (four  thick- 
nesses) laid  on  the  outside  of  the  chest,  with  an  opening  in  the  centre  to 
permit  of  subsequent  operation.  The  subsequent  steps  of  the  operation 
should  be  carried  out,  in  the  manner  already  described,  after  the  lapse  of 
a  week. 

Should  the  case  be  one  of  such  urgency  as  to  warrant  incurring  the  extra 
risk,  one  must  surround  the  diseased  area  by  a  row  of  interrupted  "back- 
stitch" or  interlocking  sutures  of  catgut.  Uniting  the  parietes  to  the  visceral 
pleura  and  lung.  Do  not  take  too  deep  a  "bite"  of  lung  with  the  needle. 
If  pleural  suturing  is,  from  any  cause,  impossible,  pack  the  pleural  cavity 
as  it  is  opened  with  gauze,  as  in  the  case  of  empyema;  a  smaller  amount  of 
gauze  may  sufl&ce  if  the  gauze  packing  is  sutured  with  catgut  into  the  pleural 
opening.  It  has  been  claimed  that  aseptic  silk  sutures  applied  to  the  non- 
infected  pleura  do  not  produce  enough  irritation  to  ensure  the  formation  of 
effective  adhesions.  Silk  sutures  soaked  in  turpentine  have  been  employed 
and  found  to  be  satisfactory. 

After  the  pus  or  the  contents  of  the  echinococcic  cysts  have  been  evacu- 
ated, provision  must  be  made  for  drainage.  This  is  best  done  by  leaving 
the  wound  wide  open  and  packing  with  sterile  gauze  (iodoform  gauze  is  lia- 
ble to  lead  to  poisoning) .  Rubber  tubes  may  be  used  ij  surrounded  by  gauze. 
Tubes  unprotected  by  gauze  occasionally  cause  erosion  of  blood-vessels. 
When  there  is  much  loss  of  lung  substance  and  there  is  not  sufficient  com- 
pensatory distention  of  the  remainder  to  fill  the  resulting  void  in  the  thorax, 
the  treatment  must  be  similar  to  that  of  old  empyema,  viz.,  resection  of  an 
appropriate  amount  of  thoracic  wall.  Lung  wounds  heal  slowly  and  form 
but  few  granulations.  Epidermization  progresses  from  the  skin  alone;  any 
growth  of  epithelium  from  divided  bronchi  leads  to  persistent  fistulae  being 
formed.  As  soon  as  retraction  or  dragging  inwards  of  the  external  soft  parts 
ceases  to  progress  satisfactorily,  recovery  may  be  hastened  by  the  use  of  skin- 
flaps  obtained  in  the  neighborhood.  If  bronchial  fistulae  persist,  they  may 
be  closed  by  the  application  of  the  cautery.  It  must  be  remembered,  how- 
ever, that  a  persistent  bronchial  fistula  may  be,  in  reality,  beneficial  in  that 
it  gives  vent  to  discharges  which  would  otherwise  be  retained  and  cause  seri- 
ous trouble. 

Pnemnectomy. — Th.  Gluck,  as  early  as  1882,  elaborated  the  following 
method  of  excising  one  lung  or  part  thereof.  After  opening  the  thorax  by 
the  removal  of  a  segment  from  one  or  more  ribs,  grasp  the  lung  with  a  clamp 
and  pull  a  cone  of  it  through  the  opening  in  the  thorax.  Apply  a  ligature 
behind  the  clamp,  pull  more  of  the  lung  through  the  wound  and  apply  an- 
other clamp.  Repeat  this  process  of  pulling  the  lung  outwards  with  a  clamp 
and  ligating  until  the  desired  amount  of  lung  is  herniated  or  until  the  pul- 
monary root  is  reached.     Cut  away  the  lung  distal  to  the  last  ligature,  leav- 


272  OPERATIONS    ON   THE   CHEST. 

ing  about  one  inch  of  lung  tissue  protruding  from  the  ligature.     Suture  the 
cut  surface  of  the  stump  with  interlocking  stitches  of  catgut. 

Gluck  ("Archiv  fur  klin.  Chir.,"  Ixxxiii,  592)  reports  the  following  two 
cases  on  which  he  operated  using  the  clamp  and  ligature  method. 

R.  P.,  thirteen  years. — March  3,  1899.  Multiple,  fetid  bronchiectasis  of 
left  lung.  Resection  of  the  sixth  to  tenth  ribs.  Resection  of  the  upper  lobe 
and  total  pneumectomy  of  the  lower  lobe  of  the  left  lung.  Before  operation 
an  enormous  amount  of  gangrenous  material  was  discharged  each  day,  after 
operation  the  discharge  was  not  worth  noticing  and  had  no  bad  smell.  The 
patient  felt  well,  ran  about  and  played  with  other  children.  In  October, 
1899,  the  thoracic  wound  was  not  completely  healed;  an  operation  was  un- 
dertaken to  close  the  wound  and  the  patient  died  from  unexpected  collapse 
and  heart  failure  (Herztod).  Autopsy  showed  chronic  interstitial  and  paren- 
chymatous myocarditis.  The  bronchiectatic  process  had  been  completely  re- 
moved and  the  lung  wound  had  healed.  Heidenhain  has  resected  the  lower 
lobe  (left)  of  a  lung — the  seat  of  bronchiectatic  cavities — with  success. 

Gluck's  second  case  is  most  important.  The  patient  suffered  in  1896 
from  lymphangitis  migrans  and  thrombo-phlebitis  of  the  left  and  subsequently 
of  the  right  lower  extremities.  In  May,  1897,  there  were  left-sided  pulmonary 
infarcts;  the  left  pleura  was  twice  punctured  and  large  amounts  of  exudates 
removed.  Recovery  in  July,  1897.  In  April,  1899,  septic  phlegmon  extensor 
aspect  of  right  forearm,  which  was  nearly  healed  in  July,  when  there  was  a 
chill  with  41.5°  (Fh.  106.7)  of  fever.  Pyemia  developed  requiring:  radical 
operation  for  right  axillary  abscess  and  phlegmon  of  chest-wall  (twice);  evacua- 
tion abscess  on  sternum;  transverse  drainage,  right  ankle-joint;  operation, 
left  pleural  empyema  (twice).  In  spite  of  extensive  resection  of  ribs  and  ev- 
acuation of  pus  from  the  pleura  elastic  fibres  were  found  in  the  putrid  discharges. 
January  3,  1900,  there  were  bloody  sputum,  dyspnoea  and  extreme  weakness. 
The  thorax  was  opened  widely,  the  enormously  thickened  and  degenerated 
pleura  was  resected  and  the  whole  lower  lobe  of  the  left  lung  was  removed 
with  the  aid  of  clamps  and  ligatures.  During  the  after-treatment  the  patient 
could  breathe  freely  and  comfortably  through  the  wound  when  his  mouth  and 
nose  were  closed.  Healing  was  completed  in  nine  months.  Nine  years  after 
operation  the  scar  is  on  a  level  with  the  skin;  and  in  spite  of  the  extensive  re- 
section of  ribs  there  is  neither  deformity  of  the  thorax  nor  spine.  The  dia- 
phragm has  formed  upwards  and  the  upper  lobe  of  the  lung  was  vicariously 
expanded. 

Pericardiocentesis. — This  operation  is  indicated  both  as  a  means  of  diag- 
nosis and  of  treatment.  For  diagnostic  purposes  we  may  use  an  exploring 
or  hypodermic  syringe  provided  with  a  long  needle;  for  purposes  of  treatment 
an  aspirator  is  required.  When  the  pericardial  effusion  is  non-infective,  a 
cure  may  be  obtained  by  simple  paracentesis.  In  performing  this  opera- 
tion, the  fluid  must  be  withdrawn  slowly  and  the  suction  stopped,  tem- 
porarily, whenever  there  is  any  pulmonary  or  cardiac  distress.     It  is  unnecessary 


PERICARDIUM,  273 

and  imprudent  completely  to  evacuate  the  fluid.  The  usual  site  for  introducing 
the  aspirating  needle  is  in  the  fourth  or  fifth  intercostal  space,  one  inch  to 
to  the  left  of  the  sternum.  A  better  position  is  in  the  sixth  intercostal  space 
immediately  to  the  left  of  the  edge  of  the  sternum.  This  last  position  gives 
the  greatest  security  against  injury  to  the  internal  mammary  artery,  to  the 
pleura,  and  to  the  heart  itself. 

EXPOSURE  OF  THE  PERICARDIUM  AND  OF  THE  HEART. 

WTien  there  is  an  infective  exudate  in  the  pericardium,  operation  is  clearly 
indicated.  The  same  is  true  in  all  cases  of  wounds  in  the  cardiac  region  when 
there  is  marked  respiratory  distress  with  cyanosis  or  there  is  collapse  with 
anaemia  and  corresponding  changes  in  the  pulse,  accompanied  by  the  physical 
signs  of  pericardiac  effusion  (Kocher). 

Many  methods  have  been  devised  by  which  to  expose  the  pericardium  and 
heart;  of  these,  Ware  gives  an  excellent  account  in  the  "Annals  of  Surgery" 
(October,  1899),  but  almost  all  of  them,  e.  g.,  those  of  Podrez,  Niuni,  etc., 
assume  that  one  desires  to  expose  the  whole  pericardial  sac  in  every  case  and 
that  a  lesser  procedure  will  never  be  efficient.  Such  operations  consist  in  the 
formation  and  reflection  of  large  flaps  consisting  of  the  skin,  muscles,  costal 
cartilages,  and  sternum.  They  require  much  technical  skill  for  their  perform- 
ance. Wounds  of  the  pericardium  and  heart  call  for  immediate  attention,  and 
no  extremely  difficult  and  unnecessarily  complicated  method  should  be  taught. 
The  type  of  operation  here  taught  is  that  described  by  Kocher,  and  any  practi- 
tioner of  ordinary  dexterity  ought  to  be  able  to  perform  it,  in  emergency,  with 
comparatively  few  and  common  instruments.  The  operation  has  a  further 
advanatge  in  that  no  unnecessary  exposure  of  the  pericardium  is  called  for. 

Pericardiotomy. — (i)  Make  an  incision  down  to  the  bone  from  the 
middle  line  of  the  sternum  outwards  towards  the  left  side,  at  the  level  and  follow- 
ing the  line  of  the  sixth  costal  cartilage.  If  required,  the  incision  may  extend 
to  the  left  mammary  line.  (2)  Separate  the  perichondrium  and  all  the  soft 
parts  from  the  sixth  costal  cartilage  and  excise  the  cartilage.  This  exposes 
the  triangular  muscle  of  the  sternum  with  the  mammary  vessels,  which  are 
ligated  if  necessary.  Divide  the  tendinous  insertion  of  the  triangular  muscle 
into  the  sternum.  The  dense,  glistening  pericardium  now  lies  exposed,  and 
if  drainage  alone  is  required,  it  may  be  opened  and  the  operation  is  complete. 
If  more  room  is  required:  (3)  From  the  sternal  end  of  the  horizontal  incision 
cut  upwards  in  the  midstemal  line  to  the  desired  extent  (usually  to  the  level 
of  the  second  rib).  (4)  Separate  the  periosteum  and  soft  structures  from  the 
sternum  to  the  left  of  the  median  line.  Divide  the  fifth,  fourth,  and  third 
left  costal  cartilages  at  their  insertions  into  the  sternum.  (5)  Through  the 
horizontal  wound  push  the  exposed  margin  of  pleura  outwards.  Gradually 
lift  up  the  fifth  and  even  the  fourth  and  third  costal  cartilages,  slowly  and 
gently  pushing  back  the  pleura  from  their  deep  surface.  (6)  After  separating 
18 


274  OPERATIONS    ON    THE    CHEST. 

the  flap  from  the  pleura,  fracture  or  divide  the  costal  cartilages  in  the  flap,  at 
their  junction  with  the  corresponding  ribs.  When  this  is  done,  the  flap  can  be 
completely  reflected.  (7)  Split  the  pericardium  along  the  sternal  margin  and 
laterally  along  the  fifth  interspace.  This  gives  access  to  the  heart  from  the 
auricles  to  the  apex  of  the  ventricles.  If  more  room  is  desired,  (8)  excise  a 
sufficient  portion  of  the  sternum  by  means  of  rongeur  or  bone  forceps. 

The  pericardium  being  open,  wipe  away  blood-clots  which  may  be  present ; 
search  for  and  suture  with  catgut  or  silk  any  cardiac  wounds.  DowoHnclude 
in  the  suture  a  coronary  artery.  Close  the  pericardial  wound  with  or  without 
drainage.  Suture  or  drain  any  pleural  wounds  which  may  be  present.  Don't 
waste  time  by  trying  to  evacuate  thoroughly,  blood  from  the  pleural  cavity; 
nature  may  generally  be  relied  upon  to  attend  to  that  better  than  can  the 
surgeon. 

Tully  Vaughan  ("Journ.  A.  M.  A.,"  Feb.  6,  1909)  has  collected  statistics 
of  150  patients  operated  on  for  wounds  of  the  heart  and  comes  to  the  following 
conclusions: 

"i.  There  is  no  longer  any  question  as  to  the  propriety  of  the  operation, 
since  35  per  cent,  of  the  patients  recover,  compared  with  15  per  cent,  (according 
to  Holmes  and  Fisher,  1881)  of  recoveries  after  non-operative  treatment — a 
gain  of  20  per  cent. 

"2.  The  mortality  is  practically  the  same  that  it  was  twelve  years  ago,  when 
the  operation  was  first  introduced,  and  it  behooves  the  surgeon  to  study  the 
matter  and  find  a  means  of  improvement. 

"3.  The  two  great  causes  of  death  are  hemorrhage  and  inflammation  of  the 
pleura  or  pericardium.  Probably  little  more  can  be  done  than  has  been  done 
to  prevent  death  from  hemorrhage,  but  inasmuch  as  more  than  half  the  pa- 
tients who  survive  twenty  hours  have  infection. 

"4.  There  is  room  for  great  improvement  in  preventing  infection.  Besides 
the  observance  of  strict  asepsis  the  question  of  opening  the  pleura  and  of 
drainage  of  pleura  or  pericardium  acting  as  predisposing  causes  of  infection 
is  of  the  greatest  importance. 

"5.  As  a  rule,  therefore,  the  pericardium  and  pleura  should  not  be 
drained." 

The  principles  of  operation  on  pericardiac  and  cardiac  wounds  may  be 
summarized  as  follows:  (i)  Cleanse.  (2)  Enlarge  the  external  wound.  (3) 
Freely  expose  the  injured  pericardium  by  excision  of  portions  of  the  ribs  and 
sternum.  (4)  Attend  to  hemostasis.  (5)  Open  the  pericardium  and  remove 
effused  blood.  (6)  Attend  to  cardiac  wounds  if  present.  (7)  Close  the  wounds 
in  pericardium  and  in  pleura  if  such  be  present.  (8)  Close  external  wound 
with  or  preferably  without  drainage. 

Cardiolysis. — WTien  the  heart  becomes  adherent  firmly  to  its  pericardial 
pouch,  and  that  in  turn  to  the  sternum,  etc.,  a  distressing  and  very  fatal  series 
of  conditions  arise.  In  such  cases  the  heart  fails,  because  with  every  systole 
it  must  needs  pull  in  along  with  it  the  osseous  thoracic  wall.     No  heart  can 


CARDIOLYSIS.  275 

long  stand  the  strain  of  such  excessive  overwork.     Two  methods  of  operative 
treatment  have  been  advised. 

(A)  Delorme's  operation  consists  in  exposing  the  heart  by  temporary 
resection  of  the  thoracic  wall,  in  opening  the  pericardium,  and  in  breaking 
down  with  the  hand  the  adhesions  between  the  heart  and  pericardium.  Kocher 
has  attempted  the  operation  on  the  cadaver,  but  never  succeeded  in  avoiding 
grave  injury  to  the  heart. 

(B)  Petersen  and  Simon  have  successfully  (three  cases)  carried  out  an  opera- 
tion suggested  by  L.  Brauer.  The  object  of  the  operation  is  not  to  free  the  heart 
from  the  adhesions,  but  to  render  these  harmless.  It  is  unnecessary  to  describe 
the  steps  of  the  procedure,  which  consist  in  the  reflection  of  a  flap  of  skin  and 
muscle,  the  exposure  of  those  ribs  and  that  part  of  the  sternum  which  impede, 
by  their  rigidity,  the  heart's  action,  and  the  excision  of  these  bony  or  cartilag- 
inous structures  to  any  extent  required.  It  is  advised  to  excise  the  periosteum 
of  the  posterior  surface  of  the  sternum,  lest  new  bone  be  formed.  This  is  the 
most  difficult  step  in  the  operation.  Very  careful  hemostasis  is  essential,  because, 
when  operated  on,  the  patient  is  usually  very  weak,  but  his  circulation  soon 
regains  strength,  and  hence  hemorrhage  and  the  formation  of  a  hematoma 
may  supervene.  Petersen  advises  that  we  should  begin  the  operation  by 
excising  three  ribs,  and  then,  if  necessary,  remove  a  portion  of  the  sternum 
also. 

P.  Lecene  ("Archives  des  mal.  du  Coeur,  des  Vaisseaux  et  du  Sang.," 
Tec,  1909;  "La  Presse  Med.,"  April  23,  1910)  has  coUected  twenty  cases 
of  cardiolysis  performed  by  various  German  and  English  surgeons  where 
there  was  no  operative  mortality  and  the  results  were  notable  and  durable. 
After  operation  the  heart  became  regular,  dyspna^a  ceased  and  the  various 
forms  of  visceral  stasis  gradually  became  less,  suffering  disappeared  and  a 
relatively  active  life  became  possible. 

Alexander  Morison  ("Lancet,"  July  4,  1908  and  Nov.  20,  1909)  advised 
thoracostomy  (cardiolysis)  in  a  case  of  excessive  cardiac  hypertrophy  in  aortic 
valvular  disease  associated  with  severe  and  frequent  attacks  of  pain  but  with 
no  costo-pericardial  adhesions.  Mr.  Stabb  operated  for  Morison  and  the  re- 
sult was  most  satisfactory.  The  reasoning  of  Morison  in  his  paper  is  most 
convincing. 

OPERATIONS  ON  THE  POSTERIOR  MEDIASTINUM.* 

As  the  type  of  operations  on  the  posterior  mediastinum,  one  may  take 
that  of  Nassilov,  a  description  of  which  was  published  in  1888  and  in  1899  by 
Stoyanov.  The  following  description  closely  follows  that  of  Nassilov:  Place 
the  patient  in  the  ventral  or  semiventrai  position.  Make  an  incision  at  least 
three  inches  in  length  along  a  line  parallel  to  the  vertebral  column,  and  four 
finger -breadths  from  it.  From  each  end  of  the  vertical  cut  make  a  horizontal 
incision  towards  the  spine.     Reflect  towards  the  spine  the  musculo- cutaneous 

*  See  also  section  on  posterior  bronchotomy,  p.  211. 


276 


OPERATIONS    ON    THE    CHEST. 


V 


flap  thus  delimited.  Resect  the  exposed  portions  of  ribs  subperiosteally. 
This  requires  great  care  because  of  the  danger  of  puncturing  the  pleura.  Should 
any  pleural  wound  be  inflicted,  suture  it  immediately.  The  ribs  should  be 
resected  close  to  the  spine,  as  this  gives  most  valuable  room.  The  superior 
portion  of  the  oesophagus  (above  the  arch  of  the  aorta — Bryant)  is  accessible 
after  excision  of  portions  of  the  third,  fourth,  fifth  and  sixth  ribs  on  the  left  side; 
the  inferior  portion  after  resection  of  three  or  more  of  the  lower  ribs  on  the 
right  side.  Attend  to  hemostasis.  Carefully  separate  with  the  fingers  the 
posterior  portion  of  the  pleura  from  the  remnants  of  the  excised  ribs  attached 
to  the  spine.  When  operating  on  the  left  side,  push  the  lung  forwards  with 
the  palm  of  the  hand  and  fingers;  this  exposes  the  thoracic  aorta,  to  the  right 


Fig.  337. — {Schwartz.)     ze  Cote.  =  2d  rib.     Az.  Azygos  vein.     Tr.  =  Trachea.     Pn.=  Vagus. 

Oe.=  Oesophagus. 

of  which  lies  the  oesophagus.  The  oesophagus  may  be  recognized  by  palpation, 
and  if  necessary  by  a  sound  being  passed  into  it  from  the  mouth.  By  blunt 
dissection  with  a  grooved  director  separate  the  loose  cellular  tissue  which  en- 
compasses the  aorta,  the  large  and  small  azygos  veins,  the  pneumogastric 
nerves,  and  the  thoracic  duct.  The  oesophagus  is  now  disengaged  from  its 
surroundings. 

The  accompanying  figure  shows  something  of  the  anatomical  dij65culties 
of  the  operation. 

If  the  operation  is  for  the  removal  of  a  foreign  body  from  the  thoracic  gullet, 
the  oesophageal  wall  is  caught  with  two  forceps  and  divided  between  them 
over  the  body,  which  is  removed  with  forceps.  The  oesophageal  wound  may 
or  may  not  be  sutured;  certainly  free  drainage  of  the  wounded  posterior  medi- 
astinum is  a  necessity.  Small,  apparently  localized,  cancers  of  the  oesophagus 
may  possibly  be  excised  after  exposure  in  the  above  manner.  Inflammatory 
lesions  of  the  posterior  mediastinum  may  be  exposed  by  Nassilov's  operation 
and  subjected  to  proper  surgical  treatment. 


PART  III.— THE  ABDOMEN. 


CHAPTER  XXX. 
LAPAROTOMY;  CELIOTOMY ;  ABDOMINAL  SECTION. 

METHODS  OF  OPENING  THE  ABDOMEN. 

The  patient,  anaesthetized,  is  placed  on  the  operating-table.  The  limbs  and 
chest  are  well  protected  with  blankets.  The  operating-room  and  table  are  well 
heated.  The  field  of  operation  is  cleansed  and  surrounded  by  sterile  cloths 
or  towels. 

The  classical  method  of  opening  the  abdomen  is  by  the  median  incision. 

(A)  Median  Incision. — In  the  middle  line,  either  above  or  below  the 
umbilicus,  make  an  incision  through  the  skin  and  subcutaneous  tissues.  The 
length  of  the  incision  varies  according  to  circumstances,  but  to  begin  with  is 
usually  about  three  inches.  In  the  linea  alba  divide  the  firm  structures  con- 
stituting the  essential  belly-wall.  As  a  rule,  hemorrhage  will  be  trifling  and 
may  be  disregarded,  but  if  any  vessels  bleed  amazingly,  apply  clamps  or  liga- 
tures before  opening  the  peritoneum.  Pick  up  a  small  fold  of  peritoneum  in 
forceps  and  cautiously  make  a  very  small  incision  through  it.  When  satisfied 
that  the  peritoneum  is  opened,  catch  each  side  of  the  peritoneal  wound  in  a 
hemostat  and  by  crossing  the  forceps,  temporarily,  close  the  belly  until  the  hands 
can  be  once  more  rinsed,  first  in  an  antiseptic  solution  and  then  in  water  or 
salt  solution.  Enlarge  the  peritoneal  wound;  introduce  the  finger  to  explore. 
Enlarge  the  incision  with  scissors,  if  such  enlargement  be  necessary  to  permit 
of  further  operative  procedures. 

If  it  be  necessary  to  enlarge  the  incision  beyond  the  umbilicus,  cut  around 
that  structure  generally  to  its  left  side,  or  even  excise  it,  since  it  is  not  suitable 
for  suturing  and  it  is  impossible  thoroughly  to  cleanse  it. 

(B)  Chevrier's  Incision. — Incise  the  skin  in  the  middle  line  and  expose 
the  anterior  layer  of  the  rectus  sheath.  Reflect  the  skin  to  one  side  so  as  to 
lay  bare  the  fascia  for  a  distance  of  i/  2  to  3/4  inch  from  the  middle  line. 
Incise  the  fascia  about  1/2  inch  from  the  middle  line  and  reflect  the  fascial 
flap  A,  B,  C,  D,  the  pedicle  of  which  corresponds  to  the  middle  line  (Fig.  338). 
Reflect  the  flap  a  little  beyond  the  middle  line  so  as  to  expose  the  median  border 
and  a  little  of  the  surface  of  the  opposite  rectus  muscle. 

Retract  the  rectus  so  as  to  expose  the  posterior  layer  of  the  rectus  sheath. 
Incise  the  sheath.     In  closing  the  wound  proceed  as  follows:  Suture  the  wound 

277 


278 


laparotomy;  celiotomy;  abdominal  section, 


in  the  posterior  layer  of  the  sheath.  In  order  to  keep  this  Hne  of  suture  from 
sHding  towards  the  middle  line,  introduce  at  each  end  the  sutures  X  X' and 
Y  Y'  which  penetrate  the  anterior  layer  of  the  sheath,  the  rectus  muscle  and  the 
upper  and  lower  ends  of  the  sutured  wound.  Tie  sutures  X  X'  and  Y  Y'  only 
after  suture  of  the  anterior  layer  of  the  sheath. 

Suture  the  edge  (E  F)  of  the  defect  in  the  anterior  fascia  to  the  base  (A  D) 
of  the  flap  (A,  B,  C,  D,  Fig.  339).  Tie  the  sutures  X  X'  and  Y  Y'.  Suture  the 
edge  B  C  of  the  flap  A,  B,  C,  D  to  the  surface  of  the  fascia  along  the  line  Z,  Z,  Z 
(Fig.  339).     Close  the  skin  wound. 


Fig.  338. 


Fig.  339. 


-AI\IT.FASC/A. 

/t£cr/. 

POSr.fASC/A 

&Pf/i/ro/V£VM. 


Fig.  340. 

The  result  of  the  procedure  is  shown  in  Fig.  340. 

(C)  Lennander's  Method. — (Kammerer;  Battle;  Jaboulay.)  Make  a 
vertical  incision  a  short  distance  to  the  right  or  left  of  the  median  line,  exposing 
the  anterior  surface  of  the  rectus.  Incise  the  anterior  layer  of  the  rectus  sheath. 
Retract  the  inner  edge  of  the  rectus  outwards,  exposing  the  posterior  layer  of 
its  sheath,  and  incise  that  layer.  Open  the  peritoneum.  Note  that  the  rectus 
muscle  itself  is  neither  incised  nor  spHt,  and  hence  its  nerve-supply  is  not  in- 
jured in  the  slightest.     In  closing  the  wound,  remember  to  suture  each  layer 


ABDOMINAL   INCISIONS. 


279 


of  the  rectus  sheath  separately  (Fig.  341).  A  similar  incision  may  be  made 
about  three-fourths  of  an  inch  internal  to  the  outer  edge  of  the  rectus,  the  sheath 
opened,  the  muscle  retracted  inwards,  and  the  abdomen  penetrated.  This 
outer  incision  is  very  commonly  used  for  exposing  the  vermiform  appendix. 

(D)  Vertical  Incision  through  the 
Rectus. — This  incision  is  excellent.  Make 
a  vertical  incision  to  one  side  of  the  median 
line  down  to  and  through  the  anterior  layer 
of  the  rectus  sheath.  Split  the  rectus  muscle 
by  blunt  dissection.  Divide  the  posterior 
layer  of  sheath  and  open  the  abdomen. 

(E)  Vertical  Incision  at  the  Outer  Edge  of  the  Rectus. — This  requires 
no  special  description. 

(F)  Transverse  Incision. — To  avoid  injury  to  the  motor  nerves  of  the 
abdominal  muscles,  Kocher  strongly  advises  that  transverse  incisions  be  used 
in  the  upper  half  of  the  belly-wall  when  median  ones  are  insufficient  or  un- 


FiG.  341. 


Fig.  344. 


Fig.  345. 


Fig.  346. 


Fig.  348. 


Fig.  347. 


Fig.  349. 


suitable.     On  occasion,  he  combines  the  transverse  and  median  so  as  to  obtain 
more  room.     (See  chapter  on  the  "Gall-bladder.") 

I  (G)  Oblique  Incisions. — In  the  lower  half  of  the  abdominal  wall,  when 
it  is  desired  to  operate  remote  from  the  median  line,  incisions  are  recommended 


28o 


laparotomy;  celiotomy;  abdominal  section. 


running  obliquely  from  above  downwards  and  inwards — i.  e.,  in  the  direction 
of  the  fibres  of  the  external  oblique  muscle.  Such  avoid  division  of  important 
motor  nerves  and  permit  of  splitting  instead  of  dividing  the  external  oblique 
muscle.     (See  chapter  on  "Appendicitis.") 


METHODS  OF  CLOSING  THE  ABDOMEN. 

The  great  object  to  be  attained  in  closing  the  abdomen  is  the  prevention 
of  subsequent  hernia.  In  the  attempt  to  gain  this  end,  surgeons  have  adopted 
a  vast  number  of  methods  of  suture.  A  study  of  the  annexed  diagrams  (Figs. 
342  to  349)  will  explain  the  suture  methods  more  clearly  than  any  printed 

description.  The  buried  sutures  unit- 
ing peritoneum  or  fascia  are  best  in- 
troduced with  full  curved  or  short 
straight  needles,  and  may  be  catgut, 
silk,  silkworm-gut,  or  silver  wire. 
The  needle  of  A.  Reverdin  (Fig.  350) 
permits  exceedingly  rapid  sewing. 
The  author  now  uses  it  constantly 
for  buried  sutures;  for  cutaneous 
sutures  it  is  not  so  good.  The  writer 
prefers  some  form  of  catgut,  either 
mililly  chromicized  or  iodized.  Kocher 
thinks  silk  the  only  proper  material. 
In  the  Johns  Hopkins  clinic  silver  wire 
is  used.  Other  surgeons  prefer  silk- 
worm-gut, tendon,  aluminum-bronze 
wire,  etc.  When  properly  used,  each 
material  does  good  work.  When 
"  through-and-through "  sutures  are 
used — i.  e.,  sutures  embracing  in  their 
loop  the  whole  thickness  of  the  belly- 
wall — some  form  of  handled  needle, 
such  as  Reverdin's  (not  A.  Reverdin's) 
or  Mixter's,  is  most  convenient  and  saves  much  time,  but  any  good  straight  or 
cur\'ed  needle  of  proper  size  will  suffice.  Some  surgeons,  e.  g.,  Jonnesco, 
object  to  the  use  of  absorbable  sutures,  of  non-absorbable  buried  sutures,  and 
yet  desire  to  close  the  abdominal  wound  in  layers.  For  this  reason  they  have 
devised  more  or  less  complicated  means  of  suturing,  so  that  they  can  remove 
the  stitches  when  they  have  served  their  purpose  (Figs.  351,  352,  353,  354). 

In  extremely  rare  instances  a  wound  does  not  heal  by  the  time  catgut 
sutures  are  absorbed.  This  peculiarity  has  caused  a  number  of  disasters. 
It  is  wise  to  reinforce  the  catgut  sutures  by  two,  three  or  four  silkworm-gut 
relaxation  stitches. 


Fig.  350. 


CLOSURE    OF  ABDOMEN. 


281 


The  inexperienced  surgeon,  after  completing  a  prolonged  operation  on  an 
exhausted  individual,  sometimes  forgets  that  it  is  better  to  have  a  post-operative 
hernia  in  a  living  patient  than  a  perfectly  closed  vi^ound  in  a  corpse.  Under 
some  circumstances  it  is  wise  to  put  in  as  few  stitches  as  possible,  and  these  in 
the  quickest  manner  possible. 


Fig.  351. — JoNNEsco's  Method'(Modified). 


Fig.  353.— Davison's  Method.  Fig.  354. 

A.  Slip-knot  to  prevent  suture  being  pulled  Continuous  sutures  fixed  by 

through   the   tissues.      The  free  end  of  the  pad  of  gauze  at  A. 

suture  is  left  projecting  from  the  wound,  and 
when  pulled  upon  unties  the  slip-knot  and  so 
permits  extraction  of  the  suture.  B.  Slip- 
knot tied  when  suture  is  in  place.  Untie  the 
same  way  as  A. 

When  drainage  has  been  used,  it  is  good  practice  to  place  sutures  in  position 
for  the  closure  of  the  opening  left  by  the  removal  of  the  drain  and  tighten  and 
tie  these  subsequently. 

When  drainage  is  necessary  it  is  often  wise  to  establish  it  through  a  special 
incision  or  stab,  and  then  close  the  primary  wound  completely.  The  means 
used  to  provide  drainage  is  liable  to  cause  trouble  in  the  main  wound. 


282  laparotomy;  celiotomy;  abdominal  section. 

POSITION  OF  PATIENT  DURING  OPERATION. 

In  most  abdominal  operations  the  ordinary  dorsal  position  suffices.  Fre- 
quently, when  the  lower  part  of  the  belly  is  invaded,  it  is  of  enormous  advantage 
to  have  the  intestines  well  out  of  the  way;  this  advantage  is  obtained  by  elevat- 
ing the  pelvis  and  depressing  the  shoulders  (Trendelenburg's  position).  The 
angle  of  inclination  may  be  as  much  as  45  degrees.  In  the  region  of  the  gall- 
bladder the  intestines  may  be  kept  out  of  the  way  by  placing  a  sand-bag  about 
five  inches  in  diameter  under  the  back,  opposite  the  lower  dorsal  vertebrae. 

DRESSINGS. 

After  completion  of  the  operation,  cover  the  wound  with  a  number  of  pads 
of  sterile  absorbent  gauze;  over  these  place  a  liberal  quantity  of  sterile  absorbent 
cotton.  Keep  the  dressings  in  place  with  a  binder,  or  preferably  by  strips 
of  adhesive  plaster.  Abundant  dressings,  snugly  applied,  support  the  intra- 
abdominal blood-vessels  and  prevent  the  patient  from  bleeding  into  his  own 
veins. 

TREATMENT  AFTER  LAPAROTOMY. 

Return  the  patient  to  bed.     A  small  pillow  may  be  placed  under  the  head 
but  for  a  short  time  the  head  must  not  be  elevated.     If  there  is  much  pain  give 
an  efficient  dose  of  an  opiate,  as  suffering  and  restlessness  are  greater  evils 
than  are  the  noxious  effects  of  the  opiate  itself.     Rectal  instillations  of  salt 
solution  are  of  great  value  in  relieving  thirst  and  in  providing  the  patient  with 
needed  liquid.     If  the  rectum  is  irritable,  hypodermoclysis  is  often  valuable. 
Washing  the  mouth  with  water  is  of  value  in  relieving  thirst  and  is  very  grateful 
to  the  patient.     As  soon  as  nausea  passes  off,  begin  giving  small  doses  of  water, 
preferably  hot,  by  the  mouth.     If  this  is  well  borne  the  patient  may  soon  be 
permitted  to  drink  two  or  more  pints  per  day.     Orange  juice  is  greatly  appre- 
ciated by  most  patients  and  to  it  a  little  egg  albumen  may  be  added  with  ad- 
vantage.    In  most  cases  liquid  nourishment  may  be  given  sparingly  in  12  or 
24  hours  after  operation.     If  the  patient  likes  butter- milk,  this  makes  an  ex- 
cellent food  to  begin  with.     Patients  rarely  feel  comfortable  until  after  the  bowels 
have  moved.     Sometimes  an  enema  of  soapy  water  with  a  little  glycerine  or 
turpentine  fulfills  the  purpose.     Usually  on  the  day  following  operation  the 
author  prescribes  calomel  gr.  1/8  to  1/4  with  soda  ever}'-  two  hours  until  the 
bowels  begin  to  grumble  and  then  gives  a  saline  aperient  or  an  enema.     If 
there  is  trouble  in  expelling  flatus,  a  rectal  tube  should  be  introduced  and  left 
in  place.     Vogel  arid  later  von  Hippel  impressed  with  the  importance  of  the 
early  establishment  of  peristalsis  in  the  prevention  of  adhesions  and  postopera- 
tive ileus,  have  advised  the  hypodermic  administration  of  physostigmin,  mg.  i, 
every  three  hours  until  the  bowels  grumble,  when  a  rectal  tube  is  passed  to 
facilitate  the  escape  of  gas.     On  the  day  following  operation,  a  glycerine  enema 
evacuates  the  bowels. 


INTESTINAL    CLAMPS. 


28' 


A  few  years  ago  many  surgeons  considered  it  essential  to  keep  patients  in 
the  dorsal  position  for  a  long  time  after  laparotomy.  This  is  cruel  and  injurious. 
Permit  the  patient  to  lie  in  whatever  position  is  comfortable  so  long  as  it  does 
not  exert  tension  on  the  wound.  After  certain  operations — e.  g.,  those  on  the 
stomach  and  those  for  peritonitis — the  above  rule  may  not  prevail.  After  oper- 
ations on  the  upper  half  of  the  abdomen  it  is  permissible  to  allow  the  patient 
to  sit  up  early,  as  the  sitting  posture  does  not  increase  tension  on  the  wound  to 
any  great  extent.  After  operations  on  the  lower  half  of  the  belly,  the  sitting 
posture  means  increased  tension  on  the  wound  and  hence  increased  risk  of 
hernia,  therefore  the  author  usually  adheres  more  or  less  closely  to  the  rules 
formulated  for  the  after-treatment  of  hernia  operations.  When  the  abdomen 
has  been  opened  by  the  gridiron  method  of  McArthur  and  McBurney,  the  above 
remarks  do  not  apply.  The  tendency  of  surgeons  is  towards  letting  the  patients 
sit  up  and  move  about  at  an  early  date,  even  a  very  early  date,  after  operation, 
but  to  the  author  it  appears  risky  as  tension  on  a  wound  insufficiently  solidi- 
fied is  well  calculated  to  cause  hernia.  The  avoidance  of  tympany  during 
convalescence  is  of  great  importance  for  the  same  reason,  viz.,  the  tension  it 
exerts  on  the  wound. 


ABDOMINAL  OPERATIONS. 

Before  describing  the  individual  operations  performed  on  the  gastro-intes- 
tinal  canal  it  will  be  convenient  to  consider  the  means  at  our  disposal  for  pre 
venting  the  escape  of  its  contents  from  an  in- 
cised gut  and  of  closing  intestinal  openings  by 
means  of  sutures.  Some  special  methods  of 
suturing  will  be  described  later,  along  with 
the  operations  for  which  they  were  devised. 

Preparation  of  a  Loop  of  Gut  for  Inci- 
sion.— With  the  finger  and  thumb  express   the   fit,,., 
contents  of  the  selected  portion  of  gut  either 
upwards  or  downwards  so   as   to   leave  that 


Fig.  355. 


Fig.  356. 


portion  empty.     Prevent  the  return  of  the  contents  to  the  loop  of  gut  by  ap- 
propriate clamps,  applied  above  and  below.     When  available,  the  best  clamps 


284 


laparotomy;  celiotomy;  abdominal  section. 


are  the  fingers  of  an  assistant  exercising  pressure  on  the  gut.  The  objections 
to  this  are  that  the  fingers  are  liable  to  take  up  too  much  room,  and  that  the 
hands  of  the  assistant  become  so  fatigued  that  he  can  give  but  little  assistance 
during  the  rest  of  the  operation.  If  plenty  of  help  is  at  hand,  of  course  the  latter 
objection  loses  its  weight.  Murphy's  clamps  (Fig.  355)  are  excellent.  It  is 
entirely  unnecessary  to  protect  the  blades  of  this  clamp  with  rubber  tubing. 
Pean  has  suggested  a  most  convenient  intestinal  clamp  (Fig.  356)  and  one 


Fig.  358. 

which  is  always  ready.  To  the  proximal  side  of  the  catch  of  an  ordinary 
hemostatic  forceps  tie  the  end  of  a  soft-rubber  catheter  or  piece  of  drainage-tube. 
Pass  the  point  of  the  forceps  behind  the  gut  and  through  the  mesentery  close 
to  the  gut.  Open  the  forceps.  Place  the  free  end  of  the  rubber  tubing  over 
the  front  of  the  gut;  stretch  the  tubing  and  catch  it  in  the  jaws  of  the  forceps. 
The  result  is  that  the  gut  is  clamped  by  the  rubber  in  front  pressing  towards 
the  forceps  behind. 


grf^Tff^l 


Fig.  359. 


Fig.  360. 


Passage  of  intestinal  contents  may  be  stopped  oy  tying  around  the  gut 
strips  of  gauze  or  pieces  of  coarse  silk  or  catgut.  Of  course,  before  they  can 
surround  the  gut  they  must  perforate  the  mesentery.  Do  not  tie  such  materials 
tightly,  as  little  pressure  is  necessary  and  much  is  injurious. 

Maylard  extemporizes  an  excellent  clamp  by  covering  the  blades  of  a 
dissecting  forceps  with  rubber  tubing.  When  the  blades  have  been  made  to 
grasp  the  intestine,  their  points  are  kept  together  by  a  segment  of  tubing 


INTESTINAL    SUTURE. 


285 


slipped  over  them  (Fig.  357).  AH  the  above  clamps  are  good  for  the  pre- 
vention of  escape  of  intestinal  contents,  but  certain  clamps  with  long  blades 
(protected  by  rubber  tubing)  not  only  serve  this  purpose  but  control  hemorrhage 
and  may  be  employed  as  handles  by  which  the  segments  of  gut  can  be  held 
steadily  in  a  position  convenient  for  suturing,  etc.     Such  clamps  are:  Doyen's 


Fig.  361. 


(Fig.  358),  Hartmann's,  Moynihan's,  Harrington's,  Scudder's,  etc.     A  clamp 
good  for  gastro-enterostomy  is  good  for  most  intestinal  work. 

Intestinal  Suture. — The  most  common  material  for  intestinal  suture  is 
fine  twisted  silk — preferably  black.  The  disadvantage  of  silk  is  that  when  wet 
it  is  difficult  to  pass  through  the  eye  of  a  fine  needle.  To  avoid  this  difi&culty 
a  sufficiency  of  needles  should  be  threaded  before  sterilization  is  begun.  Fine 
celluloid  hemp  is  stifl  enough  to  permit  of  being  threaded  on  a  needle  while 
wet,  and  is  in  other  respects  as  satisfactory  as  silk,  hence 
is  preferable.  The  best  needles  are  the  ordinary  seam- 
stress' needles,  about  one  and  a  quarter  inches  in  length. 
Various  curved  needles  (without  any  cutting-edge)  are 
useful  and  may  be  obtained  in  any  good  instrument  store. 

The  intestinal  wall  consists  of  the  following  tunics: 
the  serosa,  the  musculosa,  the  submucosa,  and  the 
mucosa.  The  submucosa  is  the  firm,  thin  tunic  which  is 
used  in  making  sausages.  It  provides  the  most  reliable 
hold  for  a  suture. 

Lembert  Suture. — This  is  the  basis  of  almost  all  methods 
of  intestinal  suture.  Its  aim  is  to  close  an  intestinal 
wound  by  turning  the  cut  edges  inwards  and  bringing  the 
serosa  of  one  side  into  apposition  with  that  of  the  other 
side.  Halsted  has  shown  that  it  is  wise  to  include  the  submucosa  in  the  stitch. 
When  a  not  too  sharp  needle  is  introduced  through  the  serosa  and  musculosa, 
its  advance  is  easy,  but  when  it  reaches  the  submucosa,  a  slightly  increased 
resistance  is  perceptible.  It  is  said  to  be  easy  to  pick  up  some  of  the  sub- 
mucosa on  the  point  of  the  needle  without  penetrating  the  mucosa.     The  author 


Fig.  362.- — -{Monod  and 
Vanverts.) 


286 


laparotomy;  celiotomy;  abdominal  section. 


has  frequently  endeavored  to  insert  Lembert  sutures  involving  the  serosa  and 
musculosa  alone,  but  they  always  tore  out;  the  picking  up  of  a  few  fibres  of  the 
submucosa  vdthout  letting  the  needle  pass  into  the  mucosa  seems  to  be  an 
"iridescent  dream";  if  any  one  doubts  this  let  him  try  to  sew  two  sausages  to- 
gether without  touching  the  contained  meat  with  the  thread  (sausage  casings 


Fig.  363. — Alfred  H.  Gould's  Mattress  Stitch. 

Note  that  the  loop  is  reversed.     This  results  in  the  rolling  in  of  the  peritoneum  on  the  side 

of  the  loop — B  drawn  to  A. 

consist  of  the  submucous  coat  of  the  gut).  The  blood-vessels  lie  in  the  sub- 
mucosa and  in  suturing  unless  the  thread  is  passed  under  the  vessels  (i.  e., 
nearer  the  mucosa)  the  stitches  will  exercise  no  pressure  upon  them  and  thus 
serious  hemorrhage  may  and  sometimes  does  occur.  In  inserting  sutures  the 
surgeon  should  see  to  it  that  each  stitch  embraces  firm  tissue  and  will  not  cut 
out  and  that  each  stitch  goes  under  any  visible  vessel  in  its  track.  If  these  two 
rules  are  observed  good  results  will  be  obtained  no 
matter  if  the  thread  does  pass  through  the  deeper 
layers  of  the  mucosa.  The  author  knows  of  one  or 
more  cases  in  which  the  operator  took  special  pains  to 
insert  the  sutures  through  the  serosa  and  musculosa 
alone  and  nearly  lost  the  patient  from  hemorrhage. 
The  introduction  of  the  suture  is  sufficiently  shown  in 
Figs-  359'  360,  and  361. 

Halsted's  Quilted  Suture. — This  is  in  principle 
identical  with  Lembert's.  The  suture  is  introduced 
after  the  U  fashion  (Fig.  362).  Gould's  mattress 
suture  with  reversed  loop  is  admirable  (Fig.  363). 

Dupuytren's  suture  (Fig.  364),  or  continuous  Lem- 
bert, can  be  easily  and  quickly  applied,  and  when 
properly  used,  is  a  most  excellent  procedure.  In 
America  it  is  curious  to  notice  that  most  eastern  operators  use  the  interrupted 
suture,  while  the  Westerners  favor  the  continuous.  The  results  seem  as 
good  whichever  method  is  employed;  hence  the  continuous  being  the  easier 
to  apply,  it  seems  to  the  author  to  be  the  better.  It  is  important  to  observe 
the  blood-vessels  running  towards  the  wound  in  the  gut,  and  to  pass  the  needle 


Fig.  364. — (Esmarch  and 
Kowalzig.) 


INTESTINAL    SUTURE. 


28: 


under  such,  so  that  v/hen  the  edges  of  the  wound  are  inverted  by  the  tight- 
ening of  the  sutures,  these  constrict  the  vessels  and  so  prevent  hemorrhage. 
If  one  fears  that  a  continuous  suture  will  act  as  a  purse-string  and  cause  con- 
traction, one  may  obviate  this  danger  (if  danger  it  be)  by  occasionally  in- 
terrupting the  suture  by  fixing  it  with  a  knot  (interrupted  continuous  suture). 


Fig.  ^6; 


Fig.  367. 


Fig.  368. 


<^^ 


Fig.  369. 


Fig. 


ST^ 


Fig.  371. — Gely's  Suture. 


Several  methods  of  closing  an  intestinal  wound  by  different  layers  of 
suture  have  been  devised.  Some  of  these  are  illustrated  in  Figs.  365,  366, 
367,  368,  369. 

Thraugh-and-through  Sutures. — When  closing  a  wound  or  uniting  di- 
vided ends  of  gut  there  is  often  considerable  hemorrhage  and  some  danger 


288  laparotomy;  celiotomy;  abdominal  section. 

of  the  line  of  Lembert  sutures  becoming  infected  by  intestinal  contents.  To 
control  hemorrhage  nothing  is  better  than  to  unite  the  edges  of  the  wound 
with  a  continuous  stitch  of  catgut  or  silk  penetrating  all  the  thickness  of  the 
gut-wall.  This  line  of  suture  is  at  once  covered  and  hidden  by  a  row  of  Lem- 
bert or  Dupuytren  sutures,  and  serves  to  protect  the  latter  from  infection. 
Cushing's  and  Gely's  methods  of  suture  are  sufficiently  explained  by  Figs. 
370  and  371. 


CHAPTER  XXXI. 
THE  STOMACH. 

Exploratory  Operation  on  the  Stomach. — At  least  one  day  prior  to 
operation  thoroughly  wash  out  the  stomach  with  warm  water.  Repeat  this 
lavage  immediately  before  the  operation.  Be  careful  to  empty  the  stomach 
completely.  If  the  stomach  has  been  for  a  long  time  much  dilated,  do  not  empty 
it  during  the  first  lavage.  Under  these  circumstances  preparation  should 
consume  several  days.  If  the  organ  is  suddenly  or  rapidly  cleaned,  tetany 
is  very  liable  to  develop.  In  dehydrated  patients,  i.  e.,  those  who  pass  not 
more  than  500  c.c.  of  urine  in  twenty-four  hours,  it  is  of  vital  importance  to 
give  hypodermically  from  40  to  60  ounces  of  saline  solution  per  diem  for 
several  days  before  operation. 

When  diseased,  the  stomach  almost  always  lies  at  a  lower  level  than  in 
health,  hence  the  incision  need  not  be  so  near  the  ensiform  cartilage  as  might 
be  imagined  from  a  study  of  normal  anatomy. 

Having  opened  the  abdominal  cavity,  introduce  the  finger  and  palpate 
the  stomach  and  its  surroundings.  This  is  often  sufficient  for  diagnosis. 
If  it  is  not  sufficient,  pull  the  stomach  into  the  abdominal  wound,  surround 
it  with  warm  pads,  and  inspect  the  anterior  gastric  wall.  If  a  pyloric  stenosis 
is  suspected,  invaginate  a  part  of  the  stomach-wall  with  the  finger  so  that 
the  finger  penetrates  and  palpates  the  pylorus.  Gentleness  must  be  employed. 
If  it  is  desirable  to  explore  the  interior  of  the  stomach,  e.  g.,  for  ulcers, 
pack  the  abdominal  cavity  around  the  stomach  with  warm  gauze  pads.  It 
is  universally  advised  to  count  the  pads  before  beginning  the  operation.  This 
is  a  good  rule.  A  rather  better  precaution  against  losing  and  leaving  a  pad 
in  the  belly  cavity  is  to  have  6  inches  of  soft  tape  sewed  to  each  pad,  and  as 
the  pads  are  introduced  into  the  belly  to  let  the  tape  emerge  from  the  wound 
and  be  anchored  by  a  hemostat.  The  tapes  emerging  through  the  wound 
are  never  in  the  way.  The  writer  makes  it  a  rule  never  to  place  a  pad  in 
the  abdomen  without  an  anchor  affixed,  and  never  to  use  other  pieces  of  gauze 
for  sponging  inside  the  cavity  unless  they  are  held  in  sponge  forceps.  These 
rules  are  simple,  and  hence  efficient. 

Have  an  assistant  pick  up  a  fold  of  the  anterior  wall  of  the  stomach.  In- 
cise this  fold  in  a  direction  at  right  angles  to  the  long  axis  of  the  organ.  If 
there  is  fluid  in  the  stomach  and  its  walls  are  not  weakened  too  much  by 
disease,  introduce  a  blunt  tube  and  empty  the  viscus.  Introduce  the  finger 
into  and  palpate  the  stomach.  Retract  the  e<lges  of  the  wound  and  inspect 
the  interior.  In  doing  this  a  rectal  speculum  provided  with  a  diaphragm  and 
xg  289 


290  THE    STOMACH. 

21/2  inches  long  by  i  1/2  in  diameter  is  of  great  aid  and  permits  inspection 
of  the  duodenum  through  the  pylorus.  Close  the  gastric  wound  by  sutures 
of  catgut  involving  the  whole  thickness  of  the  wall;  this  row  of  sutures  to  be 
inverted  or  buried  by  a  series  of  Lembert  or  continuous  Lembert  stitches. 
Close   the   abdomen.     Return   the   patient   to   bed.     Keep   him    warm. 

Thirst,  and  later  hunger,  may  be  relieved  by  warm  water  or  nutrient  ene- 
mata.  If  possible,  do  not  give  anything  by  the  mouth  for  at  least  twelve 
hours,  and  then  only  water.  Remember  that  the  danger  arising  from  giving 
drink  or  food  by  the  stomach  in  such  cases  is  really  not  from  its  leaking  through 
the  wound,  but  from  vomiting  being  set  up  by  its  presence,  and  also  from  its 
stimulating  effect  giving  rise  to  peristalsis,  etc.*  Hypodermoclysis  is  of  in- 
estimable value  in  these  cases.  It  is  desirable  that  the  stomach  rest  until 
repair  is  advanced.  If  there  is  much  pain,  morphine  in  an  efficient  dose 
should  be  given.  If  possible  to  avoid  the  use  of  morphine  without  cruelty, 
do  so,  but  when  its  employment  is  decided  on,  administer  in  one  dose  enough 
to  insure  the  effects  desired. 

Exploratory  operations  are  strongly  indicated  "in  cases  of  rapidly  de- 
veloping cachexia  and  emaciation  with  the  symptoms  of  chronic  gastritis 
and  absence  of  HCl.  Tentative  treatment  should  not  be  prolonged  over 
three  weeks.  It  is  not  near  so  serious  a  fault  to  have  caused  the  opening 
of  a  stomach  and  found  nothing  operable,  as  to  permit  a  case  to  continue 
and  find  out  at  the  autopsy  only  that  it  was  a  circumscribed  carcinoma,  the 
removal  of  which  might  have  prolonged  life  for  years."  (Hemmeter,  "Dis. 
of  Stom.,"  p.  358.) 

Operation  for  Cardiospasm. — Mikulicz  observed  a  number  of  cases 
in  which  the  patients  suffered  severely  from  oesophageal  obstruction  due  to 
muscular  spasm  at  the  cesophageal-gastric  junction.  When  milder  means 
of  treatment  failed  he  obtained  complete  cure  by  opening  the  stomach,  pass- 
ing an  instrument  like  a  glove  stretcher  into  the  oesophagus  through  the  stom- 
ach and  thus  forcibly  stretching  the  muscle  at  fault.  Briinig  has  opened  the 
blades  of  the  Mikulicz's  forceps  as  much  as  2  1/4  inches  (6  cm.)  with  excel- 
lent  results. 

Operation  for  Ulceration  of  the  Stomach. — It  is  tempting  to  advise 
operation  in  acute  cases  of  ulceration  where  there  is  a  copious  hemorrhage, 
but  recovery  generally  ensues  under  medical  treatment  and  operation  is  proper 
only  when  the  hemorrhage  is  not  merely  copious,  but  recurrent.  Moyni- 
han  advises  strongly  against  any  search  being  made  for  the  bleeding  point; 
a  gastro-enterostomy  will  cause  all  hemorrhage  to  cease  and  permit  the  ulcer 
to  heal.  Ulcers  of  the  stomach  not  producing  stenosis  ought  to  be  buried 
by  invagination  with  sutures,  or  better,  they  ought  to  be  excised.  Unless 
the  invagination  or  the   excision  gives  rise  to  stenosis,   gastro-enterostomy 

*  Possibly  too  much  weight  is  given  to  the  dangers  of  early  feeding.  Roux  is  extremely 
heterodox,  feeding  his  gastro-enterostomy  patients  with  almost  anything  they  desire  as  soon 
as  they  desire  it. 


ULCER   OF    STOMACH.  29I 

ought  not  to  be  performed.  Every  chronic  gastric  ulcer  with  hemorrhage 
demands  operation.  Duodenal  ulcers  require  excision  or  invagination  to 
produce  permanent  stasis  plus  gastro-enterostomy,  otherwise  the  relief  afforded 
ed  by  the  gastro-enterostomy  permits  partial  healing  of  the  ulcer,  a  return 
of  the  pyloric  function  and  a  return  of  the  symptoms.  Excision  of  duodenal 
ulcers  is  rarely  necessary  as  these  ulcers  have  little  tendency  to  become  malig- 
nant. In  all  cases  of  chronic  gastric  ulcer  with  hemorrhage  operation  is  in- 
dicated. When  ulcer  gives  'rise  to  gastric  dilatation,  to  hourglass  stomach,  or 
to  gastralgia  and  dyspepsia,  operation  is  called  for;  in  fact,  inveterate  dyspepsia 
warrants  operation  after  the  failure  of  a  fair  trial  of  medicinal  means  of 
treatment. 

In  cases  of  uncomplicated  ulcer  Mikulicz  recommends  medical  treat- 
ment unless  the  disease  is  very  persistent  or  recurrent,  when  operation  is  proper, 
especially  among  the  working  classes.  In  other  non-malignant  affections  of 
doubtful  origin,  notably  those  of  a  nervous  character,  he  considers  operation 
improper. 

One  must  always  bear  in  mind  that  in  pure  neurasthenia  many  of  the 
symptoms  of  gastric  ulcer  may  be  present,  the  stomach  may  be  dilated,  etc., 
and  the  patient  may  be  in  such  a  frame  of  mind  as  to  tempt  the  surgeon  to 
perform  gastro-enterostomy.  If  the  abdomen  is  opened  and  no  scar  of  ulcer 
is  found  and  there  is  no  enlargement  of  the  gastric  lymph  nodes  indicating 
ulcer,  do  not  perform  gastro-enterostomy,  as  the  latter  state  of  such  a  patient 
is  very  liable  to  be  worse  than  the  first.  The  most  experienced  surgeons  are 
becoming  more  and  more  skeptical  as  to  the  existence  of  the  so-called  "mu- 
cous ulcers"  which  cause  bleeding  but  cannot  be  seen  either  on  the  operating 
or  postmortem  table. 

WTien  operating  for  gastric  ulcer  it  may  be  interesting  to  test  the  reliabil- 
ity of  Mackenzie's  law  of  localization.  When  the  localized  pain,  cutaneous 
and  muscular  hyperesthesia  are  situated  high  in  the  epigastrium,  the  ulcer 
is  in  the  cardiac  end  of  the  stomach;  when  these  signs  are  situated  low  in  the 
epigastrium  the  ulcer  is  near  the  pylorus.  (James  Mackenzie,  "Brit.  Med. 
Journ.,"   June  30,    1906.) 

Whenever  there  is  perforation  of  the  gastric  wall  from  ulceration,  opera- 
tion is  imperative.  Excision  of  the  ulcer  is  unnecessary.  All  that  is  neces- 
sary is  to  close  the  ulcer  with  a  single  stitch  of  catgut  and  to  infold  the  ulcer 
and  a  portion  of  healthy  stomach  with  two  rows  of  continuous  Lembert  su- 
tures. (Moynihan.)  If  there  has  been  much  soiHng,  flush  the  cavity;  "if 
the  operation  is  done  within  ten  or  twelve  hours,  a  gentle  wiping  of  the  sur- 
rounding area  with  wet  swabs  will  suffice.  Drainage,  as  a  rule,  is  not  nec- 
essary except  in  the  late  cases.  When  adopted  it  should  be  free,  a  split 
tube  and  a  gauze  wick  being  placed  in  the  original  incision  and  in  a  second 
suprapubic  opening."  Do  not  be  content  with  finding  and  closing  one  per- 
foration: look  for  more.     In  20  per  cent,  of  cases  perforations  are  multiple. 

In  the  preceding  remarks  no  account  has  been  taken  of  the  presence  of 


292  THE    STOMACH. 

adhesions,  or  of  scars  and  stenoses  resulting  from  ulceration.  Adhesions 
are  Nature's  means  of  protecting  the  peritoneal  cavity  from  general  infection, 
but  while  immediately  life-saving,  they  are  very  liable  to  occasion  much  gastric 
disturbance,  and  certainly  make  operative  interference  much  more  difficult. 
The  mere  breaking-down  of  gastric  adhesions  (gastrolysis)  often  suffices 
to  cure  apparently  inveterate  cases  of  dyspepsia.  Mayo  Robson  ("Trans- 
actions Am.  Surg.  Association,"  xix)  has  carried  out  this  treatment  fifty-six 
times  with  complete  success.  Before  closing  any  perforation  or  before  unit- 
ing bowel  to  stomach,  if  adhesions  exist,  they  must  be  so  broken  down  or 
divided  that  the  parts  to  be  united  tend  to  lie  together,  and  the  sutures  when 
inserted  keep  the  parts  together  without  any  tension.  Tension  on  sutures 
is  fatal.  The  technical  difficulties  occasioned  by  adhesions  may  dominate 
the  choice  of  operation  for  the  relief  of  ulcer  or  its  sequelae. 
Ulcers  are  most  commonly  situated  posteriorly  in  the 
pylorus  and  the  pyloric  half  of  the  lesser  curvature. 
Four-fifths  of  all  ulcers  are  in  this  limited  region.*  It 
is  very  commonly  accepted  that  chronic  gastric  ulcers 
may  and  do  act  as  the  starting-point  of  malignant  dis- 
-p       ^_^  ease.     It  is  known  that  ulcers  are  often  multiple.     Influ- 

enced by  the  above  considerations,  Rodman  has  sug- 
gested the  advisability  of  excising  the  pylorus  and  that  portion  of  the  stomach 
most  commonly  the  seat  of  ulceration.  The  lines  of  incision  advised  by  this 
surgeon  are  shown  in  Fig.  372. 

The  presence  of  ulcers  or  of  their  sequelae  is  the  most  common  occasion 
for  operations  on  the  stomach.  One  must  remember  that  there  are  two 
forms  of  non-malignant  gastric  ulcer:  When  ulcers  are  present,  the  lymph 
nodes  corresponding  to  the  diseased  area  are  generally  enlarged  and  form 
a  good  guide  to  the  location  of  the  disease. 

Gastrostomy. — The  object  of  gastrostomy  is  to  make  a  convenient  fistula 
into  the  stomach  through  which  nourishment  can  be  administered.  (Esoph- 
ageal stenosis  is  the  indication  for  the  operation,  hence  we  have  usually  to 
do  with  emaciated  and  weak  patients.  The  simplest  method  of  operating 
is  the  worst.  It  consists  in  performing  an  exploratory  gastrotomy  and  sutur- 
ing the  stomach  wound  to  that  in  the  parietes.  The  objection  to  the  above 
method  is  that  it  permits  a  constant  escape  of  the  gastric  juices.  All  the 
other  methods  of  gastrostomy  are  attempts  to  avoid  the  above-mentioned 
fault. 

(A)  Gastrostomy  with  Formation  of  Sphincter  (Hartmann;  Terrier;  Ja- 
boulay,  etc.). — By  percussion  and  palpation  define  the  lower  edge  of  the  liver 
in  the  epigastrium. 

Step  I. — Make  a  vertical  incision  i  to  i  1/2  inches  to  the  left  of  the  median 

*  Forty  per  cent,  of  ulcers  are  in  the  posterior  wall  of  the  body  of  the  stomach:  25  per 
cent,  in  the  pyloric  portion;  15  per  cent,  on  the  lesser  curvature;  only  20  per  cent,  affect  the 
anterior  wall,  but  these  furnish  80  per  cent,  of  all  the  perforations  ("Hancibuch  der  praktis- 
chen  Chirurgie,"  iii,  292). 


GASTROSTOMY.  293 

line,  beginning  at  the  lower  edge  of  the  liver  and  running  downwards  for 
about  2  1/2  to  3  inches.  Divide  the  anterior  layer  of  the  muscular  sheath  and 
split  the  rectus  itself,  but  do  not  yet  divide  the  posterior  layer  of  the  sheath. 

Step  2. — Retract  the  wound  inwards  and  thus  expose  the  posterior  layer 
of  the  rectus  sheath  and  divide  it  along  with  the  peritoneum  near  the  median 
line. 

Step  3. — Introduce  the  finger  and  pass  it  up  under  the  left  lobe  of  the  liver 
to  the  portal  fissure,  and  follow  the  gastro-hepatic  omentum  to  the  lesser 
curvature  of  the  stomach.  (Maylard,  "Surgery  of  the  Alimentary  Canal.") 
This  avoids  all  danger  of  mistaking  colon  for  stomach.  Pick  up  the  ante- 
rior wall  of  the  stomach  and  pull  a  cone  of  it  

through  the  wound.     Close  all  the  excess  of  peri-    =^:::::^^pir^^^=  I h^^. 
toneal  wound.  __^:__j^_--^g^^^^.— zaa>^-%^^_ 

Step  4. — Remove  retractors    and    permit   the  /^^omacA^ 

rectus    muscle    to    resume    its    normal    position  _ 

Fig.  ^73. 
(Fig.  373). 

Step  5. — Close  all  excess  of  abdominal  wound  and  suture  the  protruding 
cone  of  stomach  to  the  skin.  Open  the  protruding  portion  of  stomach  and 
introduce  a  soft  catheter  into  it. 

Steps  I  and  2  may  be  varied  as  follows:  Divide  the  anterior  layer  of  rec- 
tus sheath  along  the  line  of  the  skin-incision;  retract  it  inwards,  i.  c,  to  the 
right;  retract  the  whole  rectus  muscle  outwards,  exposing  and  dividing  the 
posterior  layer  of  sheath  and  the  peritoneum  near  the  median  line;  pull  out 
the  cone  of  stomach;  split  the  rectus  muscle  along  the  line  of  the  skin-incision 
and  separate  the  internal  portion  from  its  posterior  layer  of  sheath;  pull  the 
cone  of  stomach  through  the  bridge  of  muscle  thus  formed  and  suture  to  the 
skin  (Figs.  374  and  375). 

(B)  Frank's  Operation. — Step  i. — Beginning  near  the  lower  edge  of  the 
liver,  make  an  incision  downwards  and  towards  the  left,  parallel  to  and  one 
inch  below  the  left  costal  cartilages.     Length  of  incision,  2  to  3  inches. 

Step  2. — Through  the  incision  pull  out  a  cone  of  stomach  from  as  near 
its  cardiac  end   as  is  possible  without  too   much  tension. 

Step  3. — Make  a  second  skin-incision,  about  i  1/2  inches  in  length,  par- 
allel to  the  first  and  situated  over  the  left  costal  cartilages.  Undermine  the 
skin  between  the  two  incisions  and  pull  the  cone  of  stomach  through  the 
tunnel  thus  formed.     Suture  the  stomach  to  the  skin  at  the  second  incision. 

Step  4. — Close  the  first  wound  without  exerting  too  much  pressure  on  the 
cone  of  stomach  which  traverses  it.  Open  the  apex  of  the  stomach  cone. 
The   result  is  an  oblique  valvular  fistula. 

Frank's  operation  has  the  disadvantage  that,  the  stomach  being  small, 
the  peculiar  formation  of  the  fistula  causes  a  deformity  which  seriously  in- 
terferes with  the  carrying  on  of  the  normal  functions. 

(C)  M  itzel's  Operation. — The  object  of  this  operation  is  to  form  an 
efl5cient  fistula  between  the  stomach  and  the  skin  and  to  make  it  oblique, 


294 


THE    STOMACH. 


SO  as  to  prevent  leakage  of  gastric  juices.     In  time  the  obliquity  is  lost,  but 
yet  leakage  does  not  take  place. 

The  Operation. — Open  the  abdomen  through  the  rectus  muscle  by  a  two- 
inch  vertical  incision  to  the  left  of  the  middle  line.  From  the  junction  of  the 
body  of  the  stomach  and  its  pyloric  portion  pull  into  the  wound  a  fold  of  the 
stomach  near  the  greater  curvature,  and  here  make  a  small  incision,  about  the 
calibre  of  a  lead-pencil,  through  the  serosa  and  musculosa.  Pick  up  the  mucosa 
with  forceps  and  open  the  stomach  cavity.  Take  a  soft-rubber  catheter,  about 
No.  25  Fr. ;  close  one  end  of  the  catheter  or  tube  with  a  clamp  and  introduce 
the  other  end  into  the  stomach.  Fix  the  tube  to  the  gastric  wound  with  one 
or  more  catgut  sutures.     Lay  the  proximal  portion  of  the  tube  on  the  surface 


Fig.  374. 

Figs.  374  and  375.- 


Fig.  375. 
-{Monod  and   Vanverls.) 


of  the  stomach  and  bury  it  by  a  row  of  Lembert  or  continuous  Lembert  su- 
tures, as  shown  in  Figs.  376  and  377.  This  forms  a  canal  in  the  stomach- 
wall.  The  canal  should  be  i  3/4  inches  in  length  or  longer.  Unite,  with 
sutures,  the  outer  opening  of  the  canal  to  the  parietal  peritoneum.  Bring 
the  free  portion  of  the  tube  out  through  the  abdominal  wound.  Close  the 
excess  of  abdominal  wound.  Over  the  portion  of  the  tube  external  to  the 
abdomen  slide  a  short  segment  of  a  larger  tube  fitting  snugly  to  the  main 
tube.  This  outer  ring  of  tubing  is  pushed  up  to  beside  the  skin,  and  through 
it  is  passed  a  safety-pin  to  prevent  the  drain  from  penetrating  too  far  into  the 
stomach.  If  the  safety-pin  was  introduced  into  the  main  tube,  tomach 
contents  could  leak  out   alongside  of  it  and  irritate. 

(D)  Stamm-Kader  Operation. — Expose  and  open  the  stomach  as  in  the 
Witzel  operation.  Introduce  a  rubber  tube  and,  with  catgut,  suture  the 
edge  of  the  gastric  wound  to  the  tube.     With  celluloid  hemp  or  silk  suture 


GASTROSTOMY, 


295 


the  gastric  serosa,  about  1/4  inch  distant  from  the  wound,  to  the  side  of  the 
tube  all  around  it  a  short  distance  from  the  wound  (Figs.  378  and  379).  In- 
sert a  second  row  of  these  serous  sutures.  This  causes  an  inversion  or  in- 
vagination of  the  stomach-wall,  which  serves  as  an  efficient  valve.  With  Lem- 
bert  sutures  unite  the  stomach  around  the  tube  to  the  parietal  peritoneum. 
Bring  the  outer  portion  of  the  tube  through  the  abdominal  wound  at  a  con- 


FiG.  376. 


Fig.  377. 


venient  point.  Close  the  excess  of  abdominal  wound.  The  Stamm-Kader 
operation  is  the  only  one  applicable  when  the  stomach  is  much  diminished 
in  size.  It  is  an  excellent,  perhaps  the  best,  method  of  operating. 
An  easier  method  of  performing  the  operation  is  at  follows: 
Introduce  a  purse-string  suture  of  catgut  all  round  a  small  opening  in 
the  stomach-wall  exactly  as  when  a  Murphy  button  is  to  be  used.  Through 
the  opening  pass  the  bulb  of  a  Jacob's  self-retaining  catheter  into  the  stomach. 
Pull  the  catgut  suture  snugly  round  the  shaft  of  the  catheter  and  tie  it.     In- 


FlG.  378. 


Fig. 


379- 


troduce  a  purse-string  suture  of  hemp  or  silk  in  the  stomach-wall  round  and 
about  1/2  inch  distant  from  the  catheter.  As  this  suture  is  tightened  push 
the  catheter  inwards  and  invert  or  invaginate  the  stomach-wall.  Tie  the 
suture  but  leave  its  ends  long.  Using  the  catheter  as  a  handle  pull  the  stom- 
ach up  against  the  abdominal  wall.  With  a  needle  fix  the  long  ends  of  the 
purse-string  suture  to  the  peritoneum  or  the  fascia  of  the  abdominal  wall. 


296 


THE   STOMACH. 


If  desired  introduce  one  or  two  sutures  to  unite  the  stomach,  near  the  gas- 
trostomy opening,  to  the  peritoneum.  (This  is  usually  superfluous).  Close 
the  abdominal  wound.  The  catheter  protrudes  through  the  abdominal 
wall  and  aids  in  keeping  the  stomach  in  contact  with  it. 

When  the  catheter  has  served  its  purpose  it  may  be  cut  off  flush  with 
the  skin  and  its  bulbous  end  permitted  to  drop  back  into  the  stomach.  This 
modified  Stamm-Kader  operation  is  the  method  almost  always  adopted  by 
the    author. 

After-treatment. — It  is  better  to  administer  nourishment  per  rectum  for 
a  few  days  after  the  operation,  lest  vomiting  be  set  up.  If  the  patient  is  ur- 
gently in  need  of  nourishment,  it  may,  however,  be  at  once  introduced  by 
the  catheter  into  the  stomach.  For  weeks  after  operation  the  diet  should 
be  liquid;  later  solid  food  well  broken  up  or  chewed  by  the  patient  may  be 
permitted. 


Fig.  380. — {Monod  and  Vanverts.) 


Fig. 


581. — Buret's  Gastropexv. 
{Monod  and  Vanverts.) 


Gastroplication. — This  operation  is  occasionally  performed  in  cases 
of  gastric  dilatation.  It  is  exceedingly  simple  and  has  for  its  object  the  dimi- 
nution in  size  of  the  stomach. 

Step  I. — Expose  the  stomach  by  a  vertical  incision. 

Step  2. — Into  the  anterior  surface  of  the  stomach  introduce  several  rows 
of  exaggerated  Lembert  sutures  or  some  modification  thereof.  The  result 
is  an  invagination  of  segments  of  the  stomach-wall  and  consequent  decrease 
in  calibre  (Fig.  380). 

This  operation  is  not  curative,  in  that  the  cause  of  the  trouble  is  not 
touched,   and  relapse  is  the  rule. 

Gastropexy. — This  operation  has  been  performed  when,  on  account 
of  gastroptosis,  the  patient  has  become  a  chronic  invalid;  suffers  severely; 
is  much  emaciated,  and  none  of  these  conditions  is  satisfactorily  relieved 


GASTROPEXY.  297 

by  the  ordinary  non-operative  methods  of  treatment.  The  object  of  the 
operation  is  to  restore  the  stomach  to,  and  retain  it  in,  its  normal  position, 
and  thus  prevent  dragging  upon  the  gastro-hepatic  omentum  and  pressure 
upon  the  intestines  and  pelvic  organs,  as  well  as  obstruction  to  the  onward 
passage  of  food  from  the  stomach  offered  by  kinking  of  the  duodenum.  The 
condition  present  is  usually  one  of  general  visceral  ptosis,  hence  the  opera- 
tion is  commonly  futile. 

Buret's  Operation. — Step  1. — Make  an  incision  in  the  median  line.  Open 
the  peritoneum  and  expose  the  stomach  in  the  lower  part  of  the  wound.  Ex- 
pose but  do  not  open  the  peritoneum  in  the  upper  part  of  the  wound. 

Step  2. — Insert  a  continuous  suture  on  the  modified  Lembert  plan,  so  as 
to  unite  the  stomach  and  upper  undivided  por- 
tion  of   peritoneum.      When    this   suture   is   in 
place,  make  both  ends  of  it  penetrate  the  fibro- 
muscular  belly-wall  and  tie  them  there  (Fig.  381). 

Step  3. — Close  the  wound. 

Rov sing's  Operation. — Step  i. — Make  a  median 
incision  from  the  ensiform  cartilage  to  the  um- 
bilicus ^^^-  3^^- — Rovsing's 

Gastropexy 

Step  2. — With   the   finger   pull   the   stomach 

upwards  to  its  normal  level.     Examine  the  pylorus  for  stenosis,  etc. 

Step.  3. — Introduce  fairly  stout  silk  sutures  as  in  Fig.  382.  Do  not  tie 
them  until  the  surfaces  of  the  stomach  and  parietal  peritoneum  are  scarified 
where  they  are  to  be  apposed  and  the  belly-wall  is  sutured. 

Step  4. — Close  the  abdominal  wound  and  place  on  it  a  pad  of  gauze. 
Over  the  gauze  pad  tie  the  sutures  suspending  the  stomach.  These  sutures 
are  left  in  situ  for  three  weeks. 

The  operation  is  not  dangerous  and  has  given  some  strikingly  brilliant 
results.  ("Archiv  f.  klin.  Chir.,"  Ix,  816.) 

Gastropexy  (Beyea's  operation)  has  been  accomplished  by  means  of  short- 
ening the  supports  of  the  stomach.  The  lesser  omentum  is  thrown  into 
transverse  folds,  which  are  rendered  permanent  by  a  few  sutures.  In  in- 
troducing the  sutures  be  careful  not  to  include  any  blood-vessels  in  their 
bite.  Frederic  Eve  ("Brit.  Med.  Journ.,"  May  7,  1910)  is  a  thorough  advo- 
cate of  a  slight  modification  of  Beyea's  operation.  The  liver  is  well  raised 
by  an  assistant  and  the  lesser  omentum  fully  exposed.  The  stomach  is  sus- 
pended by  four  or  five  interrupted  silk  sutures  passed  above  through  the  up- 
per part  of  the  gastro-hepatic  omentum  and  below  through  the  lesser  curva- 
ture in  front  of  the  vessels.  The  lesser  omentum  is  much  thicker  close  to 
the  liver  than  it  is  lower  down  but  if  the  whole  membrane  is  equally  thin 
then  the  sutures  are  passed  through  the  liver  substance  itself,  just  anterior 
to  the  transverse  fissure.  Of  seven  cases  operated  on  as  above  and  observed 
for  a  sufficient  time  afterwards,  six  were  cured. 

Gastrectomy. — (A)   Partial  gastrectomy  is  indicated  in  cases  of  limited 


298 


THE    STOMACH. 


and  well-localized  tumors  of  the  stomach-wall,  as  well  as  in  cases  of  ulcera- 
tion. After  the  removal  of  the  diseased  tissue  the  wound  is  to  be  closed  by 
a  line  of  continuous  sutures,  either  involving  the  mucosa  alone  or  the  whole 
thickness  of  the  stomach-wall.  This  line  of  deep  sutures  is  to  be  buried 
by  one  or  sometimes  two  lines  of  Lembert  or  continuous  Lembert  sutures. 
When  a  saddle-shaped  ulcer  or  any  disease  situated  on  the  lesser  curva- 
ture is  excised,  the  manner  of  closing  the  wound  is  very  important.  If  the 
resulting  wound  is  closed  in  the  long  axis  of  the  stomach,  a  certain  amount 
of  necessary  contraction  gives  rise  to  an  hour-glass  stomach  (Fig.  383),  the 
wound  must  be  closed  transversely.     The  best  way  to  operate  is  as  follows: 


Fig.  383. 


Step  I. — On  each  side  of  the  ulcer  apply  a  ligature  to  the  coronary  vessels. 
Make  a  longitudinal  slit  in  the  gastro-hepatic  omentum  above  the  ulcer. 
Through  this  slit  apply  a  volsellum  to  the  posterior  wall  of  the  stomach  about 
3/4  inch  beyond  the  posterior  limits  of  the  ulcer.  At  a  corresponding  point 
on  the  anterior  surface  of  .the  stomach  apply  a  second  volsellum.  By  lifting 
the  volsella,  a  transverse  fold  of  stomach  is  brought  forwards  (and  Ues  ante- 
rior to  the  gastro-hepatic  omentum)  consisting  of  the  ulcer  and  portions  of 
the   anterior   and   posterior  gastric   walls. 

Step  2. — Apply  an  intestinal  clamp  to  the  fold.  The  blades  of  the  clamps 
are  at  right  angles  to  the  long  axis  of  the  stomach  (Fig.  384). 

Step  3. — Excise  the  ulcer.  Close  the  wound  with  catgut  sutures  applied 
in  the  Connel  fashion.  Remove  the  clamps.  Apply  a  second  row  of  sutures 
(silk  or  hemp)  in  the  Lembert  fashion.  The  wound  is  so  closed  that  its  scar 
is  transverse  to  the  long  axis  of  the  stomach. 

Step  4. — Close  the  wound  in  the  gastro-hepatic  omentum. 

Transgastric  Partial  Gastrectomy. — If  an  ulcer  exists  on  the  posterior 
wall  of  the  stomach  and  is  adherent  to  the  pancreas  it  may  be  possible  to  gain 


GASTRECTOMY. 


299 


access  to  it  by  penetrating  both  the  gastro-hepatic  omentum  and  the  trans- 
verse meso-colon  and  then  to  divide  the  adhesions,  excise  the  ulcer  and  close 
the  wound  in  the  stomach.  W.  J.  Mayo  has  found  it  much  easier  in  several 
cases  to  perform  a  transgastric  operation  as  follows:  Incise  the  anterior 
wall  of  the  stomach  by  a  vertical  incision;  note  the  extent  of  the  ulcer  and 
its  adhesions;  incise  the  posterior  wall  of  the  stomach  from  the  inside  around 
and  close  to  the  ulcer.  Remove  the  ulcer,  if  necessary  shaving  off  a  thin 
surface  of  pancreas.  This  shaving  of  the  pancreas  is  not  so  formidable  as 
might  be  imagined,  because  the  inflammation  which  has  made  it  adherent 
to  the  stomach  has  converted  the  adherent  portion,  to  a  large  degree  at  least, 


Fig.  384. 

into  scar  tissue.  Close  the  posterior  gastric  wound  by  a  row  of  serous  sutures, 
then  by  a  row  of  through-and-through  chromicized  catgut  sutures  (Fig.  3S5). 
Close  the  anterior  wound  in  the  stomach. 

(B)  Complete  gastrectomy  is  indicated  when  the  whole  stomach  is  afifected 
by  malignant  disease;  or  if  only  one  part  is  evidently  affected,  the  rest  is 
in  a  suspicious  condition.  It  is  useless  to  attempt  a  complete  gastrectomy 
if  neighboring  structures  are  involved.  Connor  first  performed  this  opera- 
tion in  1889.  The  patient  lived  forty-eight  hours.  Schlatter  subsequently 
and  independently  operated;  his  patient  died  one  year  afterwards  from 
recurrence. 

The  Operation. — Open  the  belly  in  the  middle  line  by  an  incision  extend- 
ing from  near  the  ensiform  cartilage  to  the  umbilicus.  Divide  the  greater 
and  lesser  omenta  after  securing  their  vessels  by  chain  ligatures.  The  stom- 
ach remains  attached  to  the  body  by  the  oesophagus  and  duodenum.     Pull 


300 


THE   STOMACH. 


the  oesophagus  downwards  as  far  as  possible  and  apply  a  clamp  to  it  at  as 
high  a  point  as  can  be  reached.  Clamp  the  cardiac  orifice  of  the  stomach. 
Divide  the  oesophagus  between  the  clamps.  Apply  two  clamps  to  the  pyloric 
end  of  the  stomach  or  to  the  duodenum  and  divide  between  them.  Remove 
the  stomach.  Close  the  open  end  of  the  duodenum  by  a  continuous  through- 
and-through  suture  covered  by  a  row  of  Lembert  sutures,  interrupted  or  con- 
tinuous. Approximate  a  loop  of  jejunum  to  the  open  end  of  the  oesophagus. 
Anastomose  the  oesophagus  and  the  portion  of  gut  selected  by  suture  or  by 
the  Murphy  button.  Of  course,  if  the  open  end  of  the  duodenum  can  be 
approximated  to  the  oesophagus  without  undue  tension,  then  these  structures 
ought  to  be  united.     (Harvie,  "Annals  of  Surg.,"  1900,  p.  344.)     The  tech- 


FiG.  385. 

nic  of  the  operation  is  very  similar  to  that  of  pylorectomy;  in  fact,  the  latter 
operation  generally  includes  the  removal  of  so  much  of  the  stomach  that  its 
designation  is  almost  a  misnomer. 

Gastro-enterostomy,  or  anastomosis  between  the  stomach  and  intes- 
tine, is  indicated  in  cases  of  pyloric  obstruction,  gastric  dilatation,  and 
ulceration.  According  to  the  portion  of  intestine  selected  for  anastomosis, 
the   name   "gastro-duodenostomy"   or   "gastro-jejunostomy"    may  be  used. 

According  to  whether  the  gut  is  united  to  the  anterior  or  to  the  posterior 
wall  of  the  stomach,  the  operation  is  designated  "anterior"  or  "posterior 
gastro-enterostomy." 

Wolfler's  Operation. — Anterior  Gastro-enterostomy. — The  preparation  of  the 
patient  is  the  same  as  in  exploratory  gastrotomy. 

Step  1. — Open  the  abdomen  by  an  incision  in  or  near  the  middle  line, 
between  the  umbilicus  and  the  ensiform  cartilage.  The  cut  is  about  four 
inches  long  and  may  be  enlarged  by  a  transverse  section  of  the  rectus.  This 
is  very  rarely  necessary. 


302 


THE    STOIVLACH 


Fig.  386. — Anterior  Gastro-enterostom\'. — (Mayo.) 
a,  Wrong  site  for  anastomosis,     b,  Proper  site  for  anastomosis. 


GASTRO-ENTEROSTOMY. 


303 


Fig.  387.— (.1/ayo.) 


GASTRO-ENTEROSTOMY. 


305 


Step  2. — Expose  the  small  intestine  by  pulling  the  omentum  upwards 
and  to  the  left.  Find  the  jejunum  by  the  method  described  on  pages  306 
and  308.     Empty  the  loop  of  gut  and  apply  clamps  to  keep  it  empty. 

Step  3. — On  the  lowest  possible  point  of  the  anterior  wall  of  the  stomach 
select  a  spot  for  the  stomach  opening  (Fig.  386,  a).  Pull  this  portion  of  stom- 
ach and  the  loop  of  jejunum  out  of  the  belly  and  protect  the  cavity  with  gauze 
pads.  Make  an  anastomosis  between  the  stomach  and  the  jejunum,  using 
either  sutures  or  the  Murphy  button  (Fig.  387).  The  method  of  making 
the  anastomosis  is  identical  with  that  of  entero-enterostomy  (lateral  anas- 
tomosis (page  333). 


Step  4. — Cleanse  the  field  of  operation.  Put  aside  all  instruments  which 
have  touched  the  mucosa.  Inspect  the  line  of  union,  and  if  necessary  rein- 
force it  with  a  few  Lembert  sutures.  If  the  point  of  union  causes  the  intestine 
to  kink  sharply,  this  may  be  remedied  by  a  few  stitches  uniting  to  the  stomach 
a  little  more  of  the  afferent  or  efferent  portions  of  gut  or  of  both. 

Step  5. — Close  the  abdominal  wound.  The  after-treatment  is  the  same 
as  for  exploratory  gastrotomy. 

Kocher's  Gastro-enterostomy. — Step  1. — Expose  the  stomach  by  a  median 
incision  down  to  or  around  the  left  side  of  the  umbilicus.  Examine  every 
part  of  the  stomach  for  disease  or  complications.  (This  thorough  examina- 
tion of  the  stomach  ought  never  to  be  neglected,  as  complications,  e.  g.,  hour- 
glass contraction,  etc.,  may  exist  and  render  an  otherwise  perfect  operation 
entirely  useless.) 

Step  2. — Find  the  lowermost  part  of  the  stomach;  usually  this  is  at  the 
lowest  point  of  the  dilated  pyloric  portion.  At  this  point  separate  the  gas- 
tro-colic  omentum,  and  with  it  the  gastro-epiploic  artery,  from  the  stomach 
for  about  two  inches.     A  few  vessels  will  require  ligation  before  division. 

Step  3. — Throw  the  transverse  colon  upwards  and  hold  it  on  the  stretch. 


3o6 


THE    STOMACH. 


Seek  the  "plica  duodeno-jejunalis"  along  the  mesocolon  just  to  the  left  of 
the  spine.  At  this  point  hook  up  the  jejunum  with  the  finger  and  trace  it 
down  for  about  i6  inches.  Empty  this  portion  of  its  contents  and  clamp 
in  the  usual  fashion.  Kocher  uses  a  Doyen  clamp  applied  to  the  gut,  as 
in  Fig.  388,  and  another  applied  to  a  fold  of  the  stomach  at  the  point  of  anas- 
tomosis.    These  prevent  extravasation  of  contents  and  effusion  of  blood. 

Step  4. — Place  the  loop  of  gut  against,  and  at  a  right  angle  to,  the  stomach. 
The  afferent  portion  of  gut  must  be  posterior  to  the  efferent  (Fig.  390).  Choose 
the  part  of  the  gut  selected  for  anastomosis,  but  do  not  yet  incise  it. 


Fig.  389. — Modified  from  Kocher. 


Fig.  390. — {Kocher.) 


Step  5. — In  the  afferent  portion  of  gut,  near  the  place  chosen  for  the  anas- 
tomotic opening,  invaginate  its  wall  transversely,  on  the  convex  side  of  the 
loop,  and  equal  in  extent  to  1/2  its  circumference  (Fig.  389,  x,  x).  A  few 
Lembert  sutures  make  this  invagination  permanent. 

Step  6. — Suture  the  gut  along  the  line  of  invagination,  to  the  stomach, 
posterior  to  the  greater  curvature  and  just  behind  the  spot  chosen  for  the 
anastomosis.  (This  is  rendered  possible  by  the  separation  of  the  gastro-colic 
omentum  noted  in  Step.  2.)  The  effect  of  this  procedure  is  to  create  a  "spur" 
in  the  afferent  portion  of  the  intestine,  which  will  prevent  the  reflux  of  stom- 
ach contents  into  it  when  the  anastomosis  is  completed;  it  also  unites  the 
gut  to  the  stomach. 

Step  7. — Just  in  front  of  and  parallel  to  this  line  of  invagination  unite 
the  stomach  to  the  gut  by  a  continuous  Lembert  (Dupuytren)  suture  (Fig. 
390).  This  is  the  posterior  line  of  serous  sutures.  In  front  of  the  posterior 
line  of  serous  sutures  incise  the  stomach  down  to  but  not  through  its  mucous 
coat,  and  close  to  the  greater  curvature.  (In  Fig.  390,  for  the  sake  of  clear- 
ness, the  opening  in  the  stomach  is  made  at  too  high  a  level  and  that  in  the 
gut  is  too  much  curved.)  Make  a  corresponding  and  similar  incision  in 
the  intestine;  be  sure  that  the  intestinal  incision  is  transverse.     With  a  con- 


GASTRO-ENTEROSTOMY.  307 

tinuous  suture  unite  the  serosa  and  musculosa  of  the  posterior  edge  of  the 
wound  in  the  stomach  to  that  in  the  gut,  and  with  the  same  thread  unite  the 
gastric  to  the  intestinal  mucosa  after  incising  these  structures.  Unite  the 
remainder  of  the  circumference  of  the  gastric  to  the  corresponding  por- 
tion of  the  intestinal  opening  by  through-and-through  continuous  sutures. 
Cleanse  the  line  of  suture  and  its  neighborhood,  and  complete  the  anastomo- 
sis by  continuing  the  posterior  line  of  serous  sutures  around  the  front  until 
all  the  deep  through-and-through  sutures  are  entirely  buried.  It  is  very 
important  to  have  the  opening  in  the  stomach  as  large  as  possible;  thus  it 
is  made  a  little  larger  than  that  in  the  gut,  which  is  equal  to  half  the  circum- 
ference of  the  intestine. 

Posterior  Gastro-enterostomy.- — v.  Hacker's  Operation. — Moynihan's 
Method.* 

Step  I. — Expose  the  stomach  by  an  incision  3/4  inch  to  the  right  of  the 
median  line.  Examine  the  whole  stomach  and  duodenum.  No  matter  what 
condition  is  apparent  at  the  first  glance,  there  may  be  something  else  present, 
e.  g.,  a  trifid  stomach,  which  it  is  necessary  to  recognize. 

Step  2. — Lift  the  transverse  colon  and  great  omentum  out  of  the  abdomen 
and  turn  them  up  over  the  epigastrium.  Expose  the  under  surface  of  the 
transverse  mesocolon.     Choose  a  bloodless  spot  in  this  structure  and  tear 


Fig.  391. — Roosevelt's  Clamp  for  Gastro-enterostomy. 

through  it.  Have  the  assistant  push  the  posterior  wall  of  the  stomach  through 
this  opening.  Catch  a  fold  of  the  protruded  posterior  wall  of  the  stomach, 
three  inches  in  length,  in  a  gastro-enterostomy  clamp,  the  blades  of  which 
have  been  covered  with  rubber  tubing.  Many  clamps  have  been  devised 
for  gastro-enterostomy;  those  of  Moynihan,  Doyen,  Hartmann  and  Harring- 
ton are  each  excellent.  Instead  of  using  two  clamps  it  is  much  more  con- 
venient to  employ  a  three-bladed  instrument,  such  as  the  Roosevelt  clamp 
(Fig.  391).  The  special  advantage  of  the  instrument  is  the  steadiness  with 
which  the  stomach  and  intestine  are  held  together  during  the  operation.  When 
choosing  a  clamp  do  not  select  a  light  one;  a  powerful  heavy  instrument  prop- 
erly used  is  far  more  effective  and  less  liable  to  cause  injury  to  the  patient 
and  to  the  surgeon's  temper  than  is  one  which  is  too  delicate.  WTiatever 
clamp  is  used  the  points  of  the  blades  are  liable  to  remain  too  far  apart  to  re- 

*  It  is  hardly  necessary  to  remark  that  the  Murphy  button  may  be  used  in  place  of  the 
sutures. 


?o8 


THE    STOMACH. 


tain  efficiently  the  portion  of  stomach  which  should  lie  between  them.  To 
overcome  this  fault  W.  J.  Mayo's  first  assistant  allowed  the  protecting  rub- 
ber tubing  to  project  beyond  the  ends  of  the  blade  and  then  clamped  the 
two  portions  of  tubing  together  with  a  hemostat;  this  answered  every  pur- 
pose. Apply  the  clamp  in  such  a  way  that  the  portion  of  stomach  embraced 
by  it  extends  from  the  greater  curvature  obliquely  upwards  to  the  lesser  curva- 
ture and  towards  the  cardia. 

Step  3. — When  the  transverse  colon  is  pulled  firmly  upwards,  the  jejunum 
is  at  once  seen  coming  through  the  opening  in  the  transverse  mesocolon  (Fig. 
392).     This  is  the  simplest  means  of  finding  that  portion  of  the  gut.     Moyni- 

han  finds  the  duodeno-jejunal  angle  by 
sweeping  the  finger  along  the  under  sur- 
face of  the  root  of  the  transverse  meso- 
colon to  the  left  of  the  spine.  Bring  the 
jejunum  to  the  surface  and  clamp  a  por- 
tion of  it,  9  inches  from  the  angle,  in  a 
second  gastro-enterostomy  clamp.  Sur- 
geons are  constantly  lessening  the  length 
of  the  jejunal  loop  above  the  point  of 
anastomosis.  The  distance  of  9  inches 
has  been  almost  classical,  but  it  is  now 
cut  down  by  most  operators  to  4  or 
even  2  inches.  A  short  proximal  loop, 
so  long  as  it  does  not  drag  the  stomach 
upwards,  is  the  best  insurance  against 
the  "vicious  circle." 
Step  4. — Lay  the  two  clamps  side  by  side  on  the  abdominal  wall  so  that 
the  portions  of  stomach  and  jejunum  to  be  anastomosed  are  well  outside 
the  abdomen,  embraced  by  the  clamps.  Protect  the  belly  with  pads,  ^nd 
make  the  anastomosis  in  exactly  the  same  manner  as  in  the  case  of  a  lateral 
enteroenterostomy  (page  333).  The  length  of  the  continuous  Lembert  suture 
should  be  at  least  two  inches.  The  openings  in  the  stomach  and  gut  should 
be  •  I  3/4  inches,  and,  corresponding  to  this  opening,  a  strip  of  gastric 
mucosa  1/2  inch  wide  ought  to  be  removed.  Moynihan  lays  great  stress 
on  this  excision  of  the  mucosa  as  a  prophylactic  measure  against  subsequent 
contraction. 

Step  5. — The  edges  of  the  rent  in  the  mesocolon  ought  to  be  stitched  to 
the  stomach.     Return  the  viscera  to  the  abdomen  and  close  the  wound. 

Mayo's  "No  Loop"  Method. — The  jejunum  from  its  point  of  origin  at 
the  transverse  mesocolon  passes  downwards,  to  the  left  and  backwards,  i.  e., 
it  goes  into  the  left  kidney  pouch  below  the  splenic  flexure  of  the  colon.  The 
duodeno-jejunal  junction,  i.  e.,  the  origin  of  the  jejunum,  lies  about  i  1/2 
inches  to  the  left  of  the  middle  line,  i  1/2  to  2  inches  above  the  umbilicus, 
and  its  level  is  only  about  2  inches  lower  than  that  of  the  pylorus.     From  these 


Fig.  392 


GASTRO-ENTEROSTOMY. 


309 


anatomic  arrangements  it  will  be  seen  that  if  an  anastomosis  is  made  between 
the  jejunum  near  its  origin  and  the  stomach  in  the  Moynihan  line,  i.  e.,  making 
the  gastric  opening  oblique  from  below  upwards  toward  the  lesser  curvature 
and  towards  the  cardia,  the  result  must  be  a  certain  "kinking"  of  the  jejunum 
above  the  anastomosis.  This  "kinking"  has  been  found  in  a  number  of 
cases   in   which   persistent   vomiting   compelled   a   secondary   operation.     A 


Fig.  393. — Colon  and  Transverse  Mesocolon  Pulled  Upwards  Exposing  Jejunxtu. 
Exposure    stomach    through    rent    in    mesocolon.     Limited    separation    of  gasiro-colic 
omentum  and  gastro-epiploic  vessels  from  lowest  point  of  greater  cur-'ature  of  stomach  per- 
mits exposure  of  small  portion  of  anterior  wall  stomach.     Fold  of  stomach  in  clamp  consists 
of  a  small  portion  of  the  anterior  and  large  portion  of  the  posterior  wall. 


slight  change  in  the  position  of  the  gastro-enterostomy  fistula  gave  great  improve- 
ment in  the  results  obtained  by  the  Mayos,  J.  C.  Munro  and  others. 

Ste()  I. — As  in  the  preceding  operation. 

Step  2. — Draw  the  transverse  colon  out  of  the  wound  and  by  pulling  up- 
wards and  to  the  right,  bring  so  much  of  the  mesocolon  with  it  that  the  jeju- 
num becomes  visible.  Pick  up  the  jejunum  about  3  inches  from  the  origin. 
Note  the  fold  of  peritoneum  passing  from  the  jejunal  origin  to  the  transverse 


;io 


THE    STOMACH. 


mesocolon;  near  where  this  fold  joins  the  mesocolon  is  the  best  place  in  which 
to  tear  a  hole  in  the  mesocolon  and  expose  the  posterior  surface  of  the  stom- 
ach (Fig.  393). 

Sometimes  this  fold  of  peritoneum  extends  so  far  down  the  jejunum  that 
an  anastomosis  between  the  stomach  and  the  jejunum  distal  to  the  fold  leaves 
sufficient  gut  above  the  anastomosis  to  form  a  loop.  When  such  is  the  case 
divide  the  fold  of  peritoneum  as  the  avoidance  of  any  loop  of  gut  above  the 
anastomosis  is  of  prime  importance. 

Step  3. — Tear  a  hole  through  a  non-vascular  area  of  mesocolon.  Pull  a 
portion  of  the  posterior  wall  of  the  stomach  through  this  hole.  By  separating 
the  gastro-colic  omentum  and  with  it  the  gastro-epiploic  artery,  from  the 
greater  curvature  of  the  stomach  for  a  short  distance  it  is  easy  to  pull  a  por- 
tion of  the  anterior  as  well  as  of  the  posterior  wall  of  the  stomach  through  the 


Fig.  394. 


rent  in  the  mesocolon  (Fig.  393).  It  is  important  to  do  this  in  order  to  drain 
the  very  lowest  point  of  the  stomach.  Apply  a  gastro-enterostomy  clamp  to  a 
fold  of  stomach,  including  about  one  inch  of  the  anterior  wall.  The  direction 
of  the  clamp  and  of  the  contained  fold  must  be  from  right  to  left,  and  from 
above  downwards  (Fig.  393). 

Step  4. — Apply  a  similar  gastro-enterostomy  clamp  to  the  jejunum  along 
its  long  axis.  The  highest  point  of  the  gut  grasped  in  the  clamp  must  be  i  1/2 
to  3    1/2   inches  from  the   duodeno-jejunal  junction   (Fig.   394). 

Step  5. — Lay  the  two  clamps  side  by  side  and  complete  the  operation  as 
in  the  Moynihan  method,  i.  e.,  in  the  same  manner  as  an  intestinal  lateral 
anastomosis. 

Maury's  Method. — Maury's  operation  is  essentially  a  modification  of  Mc- 
G raw's,  but  is  accomplished  with  materials  always  at  hand. 


GASTRO-ENTEROSTOMY. 


311 


Steps  I,  2,  3  are  the  same  as  in  v.  Hacker's  operation,  except  that  no  clamps 
are    used. 

Step  4. — Lay  the  chosen  segment  of  jejunum  against  the  lowest  portion 
of  the  stomach.  Insert  a  row  of  Lembert  sutures,  90  degrees  distant  from 
the  mesentery,  and  so  unite  the  intestine  to  the  stomach.  Leave  the  ends 
of  this,  the  posterior  line  of  Lembert  sutures  long. 

Step  5. — Thread  a  straight,  round  needle  (darning-needle),  3  inches  long, 
with  very  strong  twine.  Introduce  the  needle  into  the  stomach  at  the  point 
A  (Fig.  395).     Be  sure  the  mucosa  is  penetrated.     The  point  A  should  be 


Fig.  395. — Maury's  Method  of  Gastro-enterostomy. 

near  the  vessels  of  the  greater  curvature,  and  the  distance  between  A  and 
X  (the  mid-point  of  the  line  of  Lembert  sutures)  should  be  less  than  the  diam- 
eter of  the  gut.  Bring  the  needle  out  from  the  stomach  at  the  point  B,  1/4 
inch  from  the  beginning  of  the  Lembert  suture.  Make  the  needle  traverse 
the  intestine  from  C  to  D  and  the  stomach  from  E  to  F.  The  points  D  and 
E  must  be  1/4  inch  from  the  ends  of  the  Lembert  suture. 

Make  the  same  needle  and  thread  traverse  the  gut  from  G  to  H,  the  stom- 
ach from  I  to  J,  and  lastly  the  gut  from  K  to  L. 

This  apparently  complicated  but  really  simple  series  of  stitches  forms 
two  equal  triangles  the  apices  of  which  (A  F,  L  G)  are  equi-distant  from 
the  middle  of  the  base  (X). 

Step  6. — Tie  the  ends  of  the  twine  (S,S')  together  very  tightly.  This  is  of 
great  importance,  as  necrosis  of  the  included  tissues  is  essential. 

Step  7. — Continue  the  line  of  Lembert  sutures  already  in  place  completely 
around  the  site  of  the  twine.     The  tying  of  the  twine  will  have  thrown  the  sur- 


312 


THE   STOMACH. 


face  of  the  gut  into  a  number  of  radiating  folds,  therefore  to  obliterate  these 
while  completing  the  Lembert  sutures  insert  the  stitches  so  far  as  possible 
at  the  bottom  of  these  sulci. 

Many  surgeons,  to  avoid  the  possibility  of  the  formation  of  a  "vicious 
circle"  (page  313),  complete  the  gastro-enterostomy  by  forming  an  anastomosis 
between  the  afferent  and  efferent  loops  of  jejunum  at  a  point  6  inches  lower 
down  the  gut  (Fig.  397).  Fowler,  to  make  assurance  doubly  sure,  encircled 
the  afferent  loop,  between  the  two  points  of  anastomosis,  with  a  silver  wire 
thread  to  obliterate  its  lumen;  the  same  object  may  be  attained  by  a  purse- 
string  suture  of  silk  around  the  gut  at  the  same  place.  Instead  of  using  the 
Fowler  wire  occlusion,  some  surgeons  completely  divide  the  afferent  loop 
between  the  two  points  of  anastomosis  and  close  the  open  ends  of  the  gut  by 
purse-string   sutures    (Fig.    396).     This   method   has   all  the   advantages  of 


Edges  of  splitin  transverse 
mesocolon  sutured  to 
stomach. 

Gastro-enterostomy. 


£ntero-enterostoniy. 


Fig.  396. 


Fig.  397. 


Roux's  operation,  but  does  not  interfere  to  the  same  extent  with  the  mesentery. 
It  is  certain  that  in  the  hands  of  most  surgeons,  the  dangers  of  the  vicious 
circle  are  less  than  those  incident  to  the  complicated  methods  devised  for  its 
avoidance.  In  cases  of  duodenal  ulcer  requiring  gastro-enterostomy  Berg 
and  Cackovic  have  supplemented  the  anastomosis  by  encircling  the  pylorus 
with  a  purse-string  suture,  and  thus  are  able  to  prevent  gastric  contents  reach- 
ing the  duodenum. 

To  prevent  the  narrowing  of  the  gastro-jejunal  fistula  which  so  commonly 
takes  place  when  cure  of  the  ulceration  permits  passage  of  food  through  the 
pylorus  the  duodenum  has  been  divided  and  the  ends  closed  by  suture.  Ob- 
literation of  the  duodenum  must  never  be  practised  if  the  McGraw  elastic 
ligature  or  Maury's  triangular  string  method  have  been  employed  in  making 
the  gastro-enterostomy.  By  these  methods  it  takes  about  seventy-two  hours 
to  establish  gastric  drainage.  Maury's  experiments  ("Surg.,  Gyn.  and  Ob- 
stetrics," May,  1906)  clearly  show  that  if,  in  dogs,  the  gut  is  divided  and  both 
ends  closed  at  any  point  nearer  to  the  pylorus  than  14  inches  (35  cm.)  and  the 
distal  segment  is  united  to  the  stomach  by  the  ligature  method,  the  dog  will 


VICIOUS   CIRCLE. 


S'^3 


promptly  die  with  symptoms  of  tetany.  The  death  in  these  cases  seems  to  be 
from  some  form  of  auto-intoxication  due  to  the  want  of  gastric  drainage,  because 
when  a  fistula  is  established  between  the  stomach  and  the  distal  portion  of  gut 
at  the  time  of  the  operation,  no  such  catastrophe  arises. 

Mikulicz-Czerny  Operation. — Mikulicz  and  Czerny  perform  a  gastro- 
jejunostomy based  on  two  simple  principles:  "First,  the  origin  of  the  jejunum 
lies  above  the  greater  curvature  of  the  stomach.  After  opening  the  transverse 
mesocolon  and  fastening  it  to  the  posterior  wall  of  the  stomach,  the  upper  three 
or  four  inches  of  the  jejunum  lie  directly  in  contact  with  the  gastric  wall,  hang- 
ing perpendicularly  with  its  free  border  (opposite  the  mesentery)  facing  the 
stomach-wall.  Second,  by  making  a  transverse 
incision  in  the  jejunum  three  or  four  inches 
from  its  origin  and  an  incision  close  to  the 
greater  curvature  of  the  stomach,  a  suture 
anastomosis  is  made  in  which  the  stomach  is 
drained  at  the  lowest  point  without  the  possi- 
bility of  kinking  the  intestine." 

Czerny  was  the  first  to  carry  out  this  opera- 
tion, but  used  the  Murphy  button.  Petersen 
notes  that  unless  the  anastomosis  is  exceedingly 
close  to  the  origin  of  the  jejunum  obstruction 
may  take  place.  Petersen  is  enthusiastic  over 
the  method.  Experience  in  America  has  not 
been  favorable  to  the  Mikulicz-Czerny  opera- 
tion;  a   reverse   vicious   circle  seems  to  have 

been  established  in  too  many  cases,  i.  e.,  material — e.  g.,  bile,  etc. — seems  to 
pass  along  the  duodenum,  enter  the  jejunum,  and  then  pass  into  the  stomach. 
In  one  case  operated  on  by  the  writer  there  was  an  unusual  and  annoying 
amount  of  vomiting  for  some  weeks  after  the  operation.  Other  surgeons  have 
had  worse  experiences. 

Roux's  Operation;  Operation  en  Y. — Steps  i,  2,  and  3,  as  in  posterior  gastro- 
enterostomy. 

Step  4. — Having  chosen  the  appropriate  portion  of  jejunum,  empty  it  of 
its  contents,  apply  two  clamps,  and  completely  divide  the  gut  between  them. 
Anastomose  with  suture  or  button  the  open  end  of  the  lower  segment  of  gut 
to  the  posterior  wall  of  the  stomach  (Fig.  398).  Anastomose  the  open  end  of 
the  proximal  or  duodenal  segment  of  the  gut  to  the  side  of  the  lower  segment  of 
gut,  a  few  inches  below  the  site  of  the  gastro-enterostomy. 

The  Vicious  Circle. — When  the  afferent  portion  of  gut  is  so  placed  that 
stomach  contents  pass  into  it  instead  of  into  the  efferent  loop,  grave  conse- 
quences are  liable  to  ensue,  and  to  the  condition  the  name  "vicious  circle"  has 
been  given.  Many  precautions  have  been  taken  to  avoid  this  accident,  but 
only  the  more  important  and  effectual  will  be  mentioned.  In  Mayo's  experience 
the  main  thing  is  to  make  the  gastric  opening  at  the  lowest  point  on  the  wall  of 


Fig.  398. —  {Monod  and  Vanverts.) 


314  THE  st6mach. 

the  stomach.  Kocher  does  the  same,  but  adds  a  protective  valve  to  the  afferent 
segment  (page  306).  The  accident  seems  to  be  very  rare  after  posterior  gastro- 
enterostomy. Roux's  operation,  "en  Y,"  almost  precludes  its  possibility, 
and  the  various  methods  of  adding  an  entero-enterostomy  to  the  gastro-enteros- 
tomy  give  safety  in  regard  to  the  vicious  circle,  but  of  course  add  distinctly  to 
the  gravity  of  the  operative  procedure.  No  symptoms  of  the  vicious  circle 
seem  to  have  followed  the  performance  of  the  no  loop  operation. 

Peptic  Ulcer. — Braun  and  Mikulicz  have  shown  that  the  duodenum  and 
upper  segments  of  the  jejunum  are  more  resistant  to  the  corrosive  action  of  the 
gastric  juices  than  are  the  lower  segments  of  gut.  In  posterior  gastro-enteros- 
tomy  the  portion  of  gut  opened  is  9  inches  below  the  duodeno-jejunal  fold, 
while  in  the  anterior  operation  it  is  16  to  20  inches  below  that  point.  Several 
cases  of  fatal  peptic  ulcer  have  been  noted  after  the  anterior  operation — hence 
this  constitutes  an  argument  in  favor  of  the  posterior  and  especially  of  the 
no-loop  method.  Mayo  Robson  has  operated  with  success  in  this  condition, 
excising  the  ulcerated  gut  and  reestablishing  the  anastomosis  after  Roux's 
method  ("Annals  of  Surg.,"  Aug.,  1904).  The  ulcers  occur  at  the  point  of 
anastomosis  or  within  4  inches  of  it. 

Choice  of  Method  by  Which  to  Effect  the  Anastomosis. — \.  Suture. — 
In  the  hands  of  experts  undoubtedly  the  method  by  suture  is  the  most  satisfac- 
tory. Few  surgeons,  however,  could  equal  Moynihan's  record  of  a  posterior 
gastro-enterostomy  (sutures)  completed  in  seventeen  minutes.  In  cases  where 
time  is  not  the  prime  consideration,  probably  this  method  is  the  best,  but  in 
the  exhausted  and  feeble  the  junior  surgeon  will  find  the  Murphy  button  and 
the  McGraw  elastic  ligature  time-saving  contrivances. 

2.  Murphy^s  Button. —  (Method  of  use,  see  page  336.)  Many  surgeons 
use  this  instrument  in  all  their  anastomoses.  It  is  not  quite  so  safe  and  efficient 
as  the  suture,  except  in  respect  to  the  saving  of  time.  Mikulicz  reserves  the 
use  of  the  button  for  cases  of  malignancy.  Moynihan  has  given  it  up  definitely 
as  unnecessary  and  hazardous.  Ochsner  gives  a  useful  warning  against  its 
employment  in  scar  tissue.  In  the  hands  of  the  average  surgeon  the  button 
holds  its  own  as  a  time-saving  and  hence  a  life-saving  instrument. 

3.  McGraw's  Elastic  Ligature. — (Alethod  of  use,  page  337).  This  ingenious 
method  occupies  a  place  midway  between  the  suture  method  and  the  button. 
It  is  more  rapid  than  the  former  and  slower  than  the  latter,  but  is  safe.  In 
the  hands  of  McGraw,  Willy  Meyer,  and  others  it  has  given  great  satisfaction. 
The  principal  disadvantage  to  it  is  that  in  emergency  one  will  almost  never 
have  the  proper  rubber  ligature  at  hand  ready  for  use. 

In  order  to  give  nourishment  early  after  gastro-enterostomy  and  at  the  same 
time  avoid  irritating  the  stomach  with  food  A.  Hammestahr  ("Centralblatt 
f.  Chir.,"  June  6,  1903)  uses  Rutkowsky's  method  of  combining  a  gastro-enter- 
ostomy and  a  gastrostomy.  A  catheter  is  entroduced  through  the  gastric 
fistula  into  the  jejunum  and  kept  in  place  until  the  stomach  is  in  condition  to 
take  care  of  food.     Feeding  is  carried  on  through  the  catheter.     On  removal 


PYLORUS. 


315 


of  the  catheter  the  fistula  quickly  closes.     The  method  seems  an  unnecessary 
complication. 

Operation  for  "Hour-glass"  Stomach. — The  figures  (399  to  404*) 
suflaciently  explain  the  methods  of  operating  on  hour-glass  contraction  of  the 
stomach.  In  Fig.  399  an  anastomosis  is  made  between  the  two  gastric  pouches, 
at  the  points  X  and  Y.  In  Fig.  402  the  cardiac  pouch,  being  large  and  depend- 
ant, is  united  to  the  jejunum.  In  Figs.  400  and  401  an  incision  is  made  through 
the  lowest  part  of  the  constriction  and  when  the  edges  of  the  cardiac  side  are 


Fig.  399. 


Fig.  400. 


Fig.  401. 


Fig.  402. 


Fig.  403. 
Figs.  399  to  404. — {Moynihan.) 


Fig.  404. 


united  to  those  of  the  pyloric  side,  the  normal  shape  of  the  stomach  is  more  or 
less  restored.  The  principal  of  this  operation  is  indentical  with  that  of  Miku- 
licz's pyloroplasty. 

Note  that  pyloric  stenosis  may  accompany  hour-glass  stomach.     When 
this  is  so,  the  condition  must  be  corrected  or  a  gastro-enterostomy  established. 


OPERATIONS  UPON  THE  PYLORUS. 

Pylorodiosis. — When  pyloric  stenosis  is  due  to  spasm  or  hypertrophy  of 
the  sphincter,  this  operation  may  be  indicated,  but  as  it  has  proved  to  be  by 
no  means  safe,  and  recurrence  of  the  trouble  is  frequent  after  its  performance, 
and  as  other  methods  give  more  certain  results,  the  operation  is  not  much  in 
favor. 

Halm's  Method  of  Performing  Pylorodiosis.— Expose  the  stomach  by  an 
incision  to  the  right  of  the  middle  line.  With  the  finger  invaginate  a  portion 
of  the  anterior  wall  of  the  stomach  and  push  it,  along  with  the  finger,  through 

*Fis;s.  31^9-404  are  taken  from  Moynihan's  work,  but  Figs.  400  and  401  have  been 
modified. 


3i6 


THE   STOMACH. 


the  pylorus.  When  the  pylorus  is  sufficiently  dilated,  close  the  abdominal 
wound. 

Loretd's  Method. — Expose  the  pylorus.  Incise  the  stomach  near  the  pylorus. 
Through  the  stomach-wound  pass  the  forefinger  of  each  hand  into  the  pylorus 
and  forcibly  dilate  it.     Instead  of  the  fingers  bougies  may  be  used. 

Pyloroplasty  (Heineke-Mikulicz  operation)  is  indicated  in  cases  of  spas- 
modic or  cicatricial  pyloric  stenosis. 


Fig.  405. 

Step  I. — Expose  the  stomach  near  the  pylorus  by  a  vertical  incision.  Explore 
the  whole  stomach  lest  coexistent  disease  be  overlooked.  Separate  adhesions 
which  may  exist  around  the  pylorus.  If  possible,  pull  the  pylorus  out  of  the 
abdomen.  Protect  the  peritoneal  cavity  with  gauze  pads.  Clamp  the  stomach 
and  duodenum  with  appropriate  instruments  {e.  g.,  Doyen's  clamps). 

Step  2. — Make  a  small  opening  into  the  stomach  near  the  stenosis.  Pass  a 
finger  or  an  instrument  through  the  pylorus  as  a  guide.     It  is  generally  advised 


Fig.  407. 

to  make  a  longitudinal  incision  through  the  anterior  wall  of  the  pylorus,  com- 
pletely dividing  the  stricture,  and  then  to  convert  the  longitudinal  into  a  trans- 
verse wound  and  close  it  by  sutures  (Figs.  405,406).  But,  as  Mikulicz  remarked, 
"that  is  not  the  way  we  do  it."  According  to  him,  the  longitudinal  incision 
is  made  on  the  under  surface  of  the  stenosed  pylorus  (Fig.  407,  A,  B,  C). 
Having  made  this  inferior  incision,  unite  the  posterior  edges  of  the  wound  first 
by  a  continuous  or  interrupted  row  of  Lembert  sutures,  and  then  by  a  row  of 


PYLOROPLASTY, 


317 


sutures  embracing  the  whole  thickness  of  the  walls.  Continue  the  latter  row 
so  as  to  close  the  anterior  edges  of  the  wound,  and  complete  the  union  by  in- 
serting an  anterior  row  or  Lembert  sutures.  It  is  very  evident  that  this  method 
possesses  all  the  good  qualities  of  that  usually  described,  and  has  the  great 
advantage,  in  addition,  that  it  lowers  the  level  of  the  exit  of  the  stomach. 

In  cases  of  congenital  obstruction  of  the  pylorus  the  Finney  operation  may 
be  indicated,  but  Jas.  H.  NicoU's  results  have  been  so  excellent  that  his  methods 
require  weighty  consideration.  Nicoll  ("Glasgow  Med.  Journ.,"  April,  1906) 
divulsed  the  pylorus  in  seven  cases,  with  cure  in  five  and  no  relief  in  two.  Be- 
cause of  the  failures  he  concluded  divulsion  plus  gastro-enterostomy  was  more 
ideal  but  the  mortality  of  this  in  infants,  is  50  per  cent,  or  more.     Nicoll  devised 


{Nicoll,  "Glasgow  Med.  Journ.") 


a  plastic  operation  which  he  performed  on  six  consecutive  cases  with  one  death 
and  five  cures.  The  operation  may  be  done  either  with  or  without  dividing 
the  mucosa. 

NicolVs  Pyloroplasty. — Method  A. — Step  1. — Expose  the  pyloric  region. 
Apply  rubber-covered  clamps  to  the  stomach  and  duodenum. 

Step  2. — Puncture  the  stomach.  Through  the  puncture  pass  a  closed 
sinus  forceps  or  clamp  into  the  stomach  and  so  through  the  pylorus.  Using 
the  forceps  as  a  glove  stretcher  dilate  the  pylorus  (Figs.  408  and  409) . 

Step  3. — Make  a  /\  incision  down  to  but  not  through  the  mucosa  (Fig. 
408).  Convert  the  /\  into  a  A.  and  suture  (Fig.  409).  Close  the  puncture  in 
the  stomach  (Fig.  410). 

Method  B. — Omit  puncturing  the  stomach.  Make  the  /\  incision  through 
the  whole  intestinal  wall  (mucosa  included).  Through  the  incision  pass  the 
divulsing  forceps  and  divulse.  Convert  the  /\  into  a  A.  by  the  usual  two  rows 
of  intestinal  sutures. 

Finney's  Operation. — ^Finney's  operation  is  a  most  valuable  contribution  to 
surgery  and  in  many  cases  it  is  a  desirable  substitute  for  gastro-enterostomy. 


3i8 


THE    STOMACH, 


When  as  a  result  of  ulceration  there  is  a  spastic  condition  of  the  pylorus  the  rest 
secured  through  gastro-enterostomy  gives  a  very  brilliant  immediate  result, 
but  as  spasm  abates  food  once  more  resumes  its  normal  route  through  the  py- 
lorus, the  artificial  opening  is  liable  to  contract,  and  recurrence  of  the  trouble 


Fig.  409. — {Nicoll,  "Glasgow  Med.  Journ.") 

is  frequent.  In  such  cases  Finney's  method  is  of  great  service.  The  presence 
of  many  adhesions  is  stated  to  be  a  contra-indication  to  the  operation  but  it 
v^as  exactly  in  such  a  case,  where  adhesions  impeded  gastro-enterostomy, 
that  Finney  noticed  how  closely  and  conveniently  the  duodenum  and  stomach 


Fig.  410. — {Nicoll,  "Glasgow  Med.  Journ  ") 

lay  together  and  at  once  proceeded  to  unite  them.  Many  variations  in  tech- 
nic  have  been  devised  but  the  principles  of  all  are  the  same  and  the  author 
will  take  the  liberty  of  describing  the  operation  as  he  has  done  it  himself.* 
Clamps  may  or  may  not  be  used. 

*This  account  of  the  operation  was  submitted  to  Finney  and  met  his  approval. 


Finney's  operation. 


119 


The  Operation. — The  abdomen  having  been  opened  and  the  pylorus  with 
the  adjacent  portions  of  the  stomach  and  duodenum,  if  possible,  pulled  out  of 
the  abdominal  wound,  protect  the  peritoneum  thoroughly  with  gauze  packs. 

Step  I. — Unite  the  adjacent  surfaces  of  stomach  and  duodenum  by  a  con- 
tinuous Lembert  suture  (A,  Fig.  412).     (Posterior  line  of  serous  suture.) 

Step  2. — Make  the  Pi -shaped  incision  XYZ  (Figs.  411  and  412),  opening 
both  the  stomach  and  duodenum  and  dividing  the  pylorus. 

Step  3. — Unite  the  two  posterior  edges  of  the  (H  incision  by  means  of  Conn  ell 
sutures  or  by  a  through-and-fhrough  whipping-stitch  (Figs.  412  and  413). 
With  the  same  suture  unite  the  two  anterior  edges  of  the  P)  incision  (Fig.  413). 


Fig.  411. 


Fig.  412. 


Step  4. — Continue  the  Lembert  suture  introduced  in  Step  i,  around  the  ante- 
rior surface  of  the  anastomosis  (anterior  line  of  serous  suture)  and  bury  from 
sight  the  stitches  introduced  in  Step  3. 

Fig.  414  shows  in  section  the  result  of  the  operation. 

If  it  is  difficult  to  lay  the  duodenum  along  side  of  the  stomach  without 
tension  it  is  easy  to  make  a  vertical  incision  through  the  parietal  peritoneum 
two  finger-breadths  to  the  right  of  and  parallel  to  the  descending  portion  of 
the  duodenum  (Kocher).  The  fingers  introduced  through  the  wound  in  the 
peritoneum  easily  separate  the  duodenum  (and  with  it,  if  necessary,  the  head  of 
the  pancreas)  from  the  vertebral  column,  vena  cava  and  aorta  and  so  mobilize 
the  gut  that  Finney's  operation  becomes  easy. 

How  extensive  ought  one  to  make  the  new  opening  between  the  stomach 
and  duodenum?  Finney  makes  a  very  extensive  opening  and  finds  it  satis- 
factory. The  Mayos  think  the  lower  end  of  the  new  opening  ought  not  to 
reach  as  low  as  the  ampulla  of  Vater.     Both  methods  give  good  results. 

Pylorectomy.- — This  operation  is  commonly  supplemented  by  a  partial 
gastrectomy.  The  indications  for  its  performance  are  usually  malignant 
disease,  or  pyloric  ulcer  and  its  sequelae.     Malignant  disease  of  the  pylorus 


320 


THE    STOMACH. 


usually  spreads  towards  the  cardiac  end  of  the  stomach,  especially  along  the 
lesser  curvature;  hence  in  operating  in  malignancy  it  is  wise  to  excise  along 
with  the  pylorus  the  whole  lesser  curvature  of  the  stomach  and  all  suspected 
lymph-glands.  "In  cutting  across  the  stomach  the  incisions  should  be  i  1/2 
to  2  inches  wide  of  the  disease  at  least"  (Mayo  Robson).  As  malignant  disease 
does  not,  as  a  rule,  infiltrate  towards  the  duodenum,  the  division  of  the  duo- 
denum may  be  made  at  a  point  about  3/4  to  i  inch  away  from  the  disease. 
"  In  excising  glands  from  the  great  omentum  there  is  great  danger  of  wounding 
the  middle  colic  artery  and  thereby  causing  gangrene  of  the  transverse  colon. 
The  glands  along  the  greater  curvature  are  most  numerous  near  the  pylorus." 
(Mayo  Robson,  "Surg.  Treatment  Diseases  of  the  Stomach.")  This  danger 
is  avoided  in  the  method  described  on  page  323. 


Stomach/. 


Fig.  413. 


Fig.  414. 


In  view  of  the  facts  stated  in  the  preceding  paragraphs,  it  follows  that  the 
original  operations  of  pylorectomy  were  defective  in  extent.  When  a  sufficiency 
of  the  viscus  is  removed,  it  will  rarely,  if  ever,  be  possible  to  unite  the  open  end 
of  the  duodenum  to  the  open  end  of  the  stomach  (partially  closed  by  sutures), 
and  when  possible  it  will  be  much  more  difficult,  time-consuming,  and  risky 
than  the  methods  to  be  described. 

Kocher's  Operation. — The  preparation  for  pylorectomy  is  the  same  as  for 
gastrotomy.  The  stomach  is  exposed  by  a  vertical  incision  in  or  near  the  me- 
dian line,  supplemented  if  necessary  by  a  transverse  cut  through  the  right 
rectus. 

Ligate  the  gastrohepatic  omentum  from  the  pylorus  to  the  coronary  artery, 
and  divide  it  as  close  to  the  liver  as  possible  (Fig.  415).  This  removes  as  much 
suspected  lymphatic  tissue  as  possible.  Expose  and  tie  the  coronary  artery 
near  the  oesophageal  end  of  the  lesser  curvature.      With  the  fingers  tear 


PYLORECTOMY. 


321 


through  the  great  omentum  close  to  the  stomach,  and  through  this  rent  pass  one 
blade  of  a  clamp  (Doyen's,  Kocher's)  behind  the  stomach,  the  other  blade 
being  in  front.  Secure  the  clamp  in  position  a  little  to  the  left  of  the  line  chosen 
for  division  of  the  stomach.  Place  a  second  clamp  on  the  stomach  parallel 
to  and  one  inch  to  the  right  of  the  first.  If  the  blades  of  the  clamps  are  not 
long  enough  to  grasp  the  whole  distance  from  the  greater  to  the  lesser  curva- 
tures, they  may  be  supplemented  by  others  applied  over  the  lesser  curvatures. 
Divide  the  stomach  between  the  clamps,  either  with  a  cautery  or  a  knife;  if 
the  latter  is  used,  with  a  strong  antiseptic  cleanse  the  line  of  section.     Turn 


Fig.  415. — {Mayo,  from  sketches  by  the  author.) 

the  pyloric  end  of  the  stomach  (closed  by  clamps)  to  the  right,  thus  exposing 
its  posterior  surface  and  the  duodenum.  As  the  stomach  is  being  turned 
over,  doubly  ligate  in  sections  the  great  omentum  and  divide  it.  The  gastro- 
duodenal  artery  is  exposed  and  ligated  (Fig.  416).  These  steps  isolate  the  por- 
tion of  the  duodenum  to  be  removed.  Apply  two  clamps  to  the  duodenum 
and  divide  between  them.  Cleanse  the  cut  surface  of  the  duodenum  and  tem- 
porarily cover  it  with  gauze  after  noting  whether  or  not  it  can  be  brought  into 
contact  with  the  posterior  surface  of  the  remaining  portion  of  the  stomach. 

The  excised  portions  of  the  stomach  and  pylorus  are  thrown  aside.  The 
clamps  closing  the  stomach  being  still  in  position,  apply  a  continuous  (better 
a  shoemaker's)  suture  immediately  to  their  left — /.  e.,  to  their  proximal  side — - 
and  tie  tightly.  Remove  the  clamps  and  excise  any  exuberant  mucosa.  Apply 
a  continuous  through-and-throngh  suture  to  the  whole  stomach-wound.     Bury 


322 


THE    STOMACH. 


this  line  of  suture  by  a  line  of  continuous  Lembert  sutures,  reinforced  where 
necessary  by  a  few  isolated  Lembert  stitches.*  Bring  the  duodenum  without 
tension  into  apposition  with  the  posterior  surface  of  the  stomach.     With  a  con- 


1-      \> 
Fig.  416. — {Monod  and  Vanverts.) 


tinuous  Lembert  suture  unite  the  posterior  wall  of  the  duodenum  to  the  stomach. 
Incise  the  stomach  (Fig.  417)-  With  a  continuous  through- and-thro ugh  suture 
unite  the  open  end  of  the  duodenum  (clamps  having  been  removed  and  the 
assistant's  fingers  substituted  for  them)  to  the  gastric  opening.     This  line  of 

suture  is  hemostatic  and  temporarily  prevents 
escape  of  visceral  contents.  Continue  the  line  of 
Lembert  sutures  already  in  position  around  the 
front  of  the  gut  and  stomach,  thus  completing  the 
safe  implantation  of  the  open  end  of  duodenum 
into  the  posterior  wall  of  the  stomach  at  as  low  a 
point  as  possible. 

The  operation  as  above  described  is  unneces- 
sarily complicated;  the  union  of  the  open  end  of 
the  gut  to  the  stomach-wall  is  more  difficult,  if  the 
suture  method  is  employed,  than  is  lateral  anas- 
tomosis; above  all,  the  results  have  not  been 
nearly  so  good  as  those  obtained  from  the  next 
operation  to  be  described,  and  which,  in  the 
author's  judgment,  is  the  operation  of  choice. 

Pylorectomy  or  Partial  Gastrectomy. — The 
following  operation  may  be  dubbed  "the  Rochester 
method;"  its  basis  is  the  second  Billroth  operation. 
It  has  been  elaborated  by  the  Mayos,  and  although  almost  every  feature  of  it 
has  been  devised  by  others,  yet  these  surgeons  have  so  systematized  the  steps 

*  The  clamps  on  the  stomach  should  be  applied  with  much  force.     The  tissues  crushed 
by  them  are  not  expected  to  unite;  they  are  invaginated  by  sutures  inserted  in  sound  structures. 


Fig. 


417. — (Monod  and 
Vanverts  ) 


PARTIAL    GASTRECTOMY. 


323 


and  brought  it  to  such  a  degree  of  safety  that  the  description  here  given  is  an 
exact  account  of  their  method. 

Step  I. — Make  a  longitudinal  incision  between  the  ensiform  cartilage  and 
umbilicus  in  or  near  the  middle  line.  Explore  the  stomach  and  the  biliary 
passages  (as  routine). 

Step  2. — Ligate  the  gastric  or  coronary  artery  close  to  the  stomach  (Fig. 
415).  Ligate  the  lesser  omentum  close  to  the  liver,  in  three  or  four  segments 
and  divide  it.     Ligate  the  pyloric  branch  of  the  hepatic  artery. 


Fig.  418. — {Mayo,  from  sketches  by  tlie  author.) 


Step  3. — Pass  the  left  hand  from  above  downwards  behind  the  pylorus  and 
stomach  and  lift  forwards  the  great  omentum.  Ligate  the  right  gastro-epiploic 
artery.  Ligate,  in  three  or  four  segments,  the  great  omentum.  Interlocking 
ligatures  are  not  required.  The  left  gastro-epiploic  artery  must  be  tied  well  to 
the  left  of  the  disease,  and  in  any  case  of  cancer  well  to  the  left  of  the  last  of  the 
glands  in  the  great  omentum  which  are  related  to  the  diseased  area.  Figs. 
419  and  420  show  the  arrangement  of  the  lymphatics  of  the  stomach.  The 
great  danger  to  be  avoided  in  ligating  the  vessels  in  this  step  is  that  of  including 
in  the  ligature  the  mid-colic  artery  and  thus  causing  gangrene  of  the  transverse 
colon.  If  this  accident  occurs  or  if  the  disease  affects  the  transverse  colon  and 
is  still  operable  (Gray),  excise  the  portion  of  colon  involved  (enterectomy) . 


324 


THE    STOMACH. 


The  passage  of  the  hand  behind  the  stomach  and  the  consequent  elevation  of 
the  great  omentum  entirely  avert  the  danger  of  ligating  the  mid-colic  artery. 
Divide  the  great  omentum,  leaving  attached  to  the  stomach  that  portion  con- 
taining lymph-glands  (Fig.  418). 

As  the  gastro-colic  omentum  is  being  divided  "it  will  sometimes  be  found 
that  the  avascular  area  which  lies  in  the  circle  of  the  middle  colic  vessel  and  the 
posterior  layer  of  the  mesocolic  peritoneum  is  attached  to  the  growth.  If  this 
is  the  case  the  attached  peritoneum  can  be  cut  out  and  removed  with  the  growth. 
The  opening  thus  made  in  the  transverse  mesocolon  can  be  used  later  through 
which  to  make  the  gastro-jejunostomy"  (Mayo). 


Fig.  419. — {Cuneo.) 


Step  4. — Continue  the  ligation  of  the  gastro-coUc  omentum  close  to  the  colon 
to  a  point  rather  more  to  the  right  than  is  shown  in  Fig.  418  so  as  to  get  below 
and  to  the  right  of  the  inferior  gastro-duodenal  lymph  nodes  situated  below  and 
to  the  right  of  the  pylorus  about  the  head  of  the  pancreas.  (Fig.  421.).  Lift 
up  the  fat  and  gland  from  over  the  head  of  the  pancreas  separating  them  from 
the  curve  of  the  duodenum  but  leaving  them  attached  to  the  stomach  and 
pylorus.  During  the  above  dissection  the  vessels  anastomosing  with  the 
branches  of  the  superior  pancreato-duodenal  artery  are  exposed  and  tied. 
Continue  the  dissection  until  at  least  two  inches  of  the  inferior  border  of  the 
duodenum  is  cleared  and  the  gastro-duodenal  artery  is  exposed  in  the  groove 
between  the  head  of  the  pancreas  and  the  duodenum  behind  the  pylorus. 
Ligate  and  divide  the  gastro-duodenal  vessels.  This  permits  thorough  removal 
of  the  glands. 

Step  5. — Separate  the  posterior  surface  of  the  duodenum  from  the  pancreas. 


PARTIAL   GASTRECTOMY. 


325 


If  the  gastric  growth  is  adherent  to  the  pancreas  shave  off  a  portion  of  the  pan- 
creas leaving  the  shaved-off  portion  attached  to  the  stomach.  If  the  involve- 
ment of  the  pancreas  is  extensive  "it  is  better  to  leave  this  part  of  the  operation 
until  the  stomach  is  either  cut  across  and  separated  from  the  duodenum  or  the 
line  of  stomach  section  on  the  cardiac  side  is  finished  and  the  stomach  turned 
over  in  order  that  this  portion  of  the  dissection  may  be  completed  under  in- 
spection.    If  such  injuries  to  the  pancreas  are  properly  cared  for,  we  have  not 

found   that  they  gave  rise  to  serious  consequences The  best 

manner  of  treating  such  an  injury  to  the  pancreas  is  to  cover  it  as  far  as  practica- 


<#>- 


I  ,-ir>% 


Pneumojiasiric  Left 

Gantlion___ 

Pneumojaslric  Righr 

Coronary  Arfery  _ 
Coronary  Vein  „ 

Ganglion 


Fig.  42  o. — {Mayo,  after  Cuneo.) 


ble  with  the  sheath  and  posterior  peritoneum,  and  after  completely  closing  the 
end  of  the  duodenum,  if  possible  the  stump  of  the  duodenum  should  be  buried 
in  the  injured  surface  of  the  pancreas"  (Mayo). 

Step  6. — Apply  two  clamps  on  the  duodenum  distal  to  the  disease  and  about 
3/4  to  I  inch  apart.  The  clamps  should  be  heavy  and  applied  tightly.  With 
the  cautery,  divide  the  duodenum  between  the  clamps.  Leave  a  stump  about 
1/4  inch  long  protruding  from  the  distal  clamp. 

Step  7. — Introduce  a  continuous  catgut  stitch  through  the  end  of  the  duo- 
denal stump  protruding  from  the  forceps  (Fig.  418).     Tie  the  ends  of  this 


326 


THE    STOMACH. 


suture  firmly  together.  As  the  first  knot  is  being  tied  remove  the  clamp.  The 
result  is  that  the  end  of  the  duodenum  is  closed  and  bunched  into  a  small  com- 
pass. Bury  the  sutured  end  of  the  duodenum  by  means  of  a  purse-string 
suture  (Fig.  418).     This  completes  the  care  of  the  duodenum. 

Conrad  Brunner  ("  Centralblatt  fur  Chir.,"  1905,  No.  47)  after  a  study  of 
the  statistics  of  Czerny  and  others,  comes  to  the  conclusion  that  the  closure  of 
the  duodenum  is  often  imperfect,  especially  if  much  of  it  has  been  excised. 
To  avoid  the  dangers  of  leakage,  should  such  occur,  he  fixes  the  closed  duo- 
denal stump  extraperitoneally  into  the  upper  angle  of  the  wound  surrounding 
it  with  mobilized  parietal  peritoneum. 


Fig.  421. 

Steinthal  thinks  that  the  dislocation  of  the  duodenal  stump,  inseparable 
from  Brunner's  method,  is  dangerous,  therefore  he  places  a  tampon  against 
the  stump  when  so  much  of  the  duodenum  has  been  removed  that  efiicient 
closure  is  uncertain.  In  America  most  surgeons  fix  a  cigarette  drain  to  the 
suspected  stump  by  means  of  a  fine  catgut  suture. 

Step  8. — Choose  the  line  of  section  on  the  stomach.  This  line  must  be  to 
the  left  of  the  lymphatic  glands,  into  which  the  diseased  area  drains  (Figs.  419 
and  422).  Immediately  to  the  cardiac  side  of  the  line  of  section  apply  a  Kocher 
clamp,  the  blades  of  which  are  protected  with  rubber  tubing.  To  the  right  of 
the  line  of  section  apply  crushing  clamps  of  any  convenient  variety.  These 
latter  clamps  merely  prevent  escape  of  contents  from  the  segment  of  stomach 
about  to  be  removed.  Divide  the  stomach  along  the  line  of  section  with  the 
cautery,  leaving  a  stump  of  about  1/4  inch  protruding  from  the  Kocher  clamp. 
As  the  section  is  being  made  seize  the  protruding  stump  in  three  or  four  places 


PARTIAL    GASTRECTOMY. 


327 


with  small  volsella  or  hemostats  to  prevent  the  stump  slipping  through  the 
Kocher  clamp.  This  precaution  is  important,  as  such  slipping  means — (a)  that 
stomach  contents  may  escape  and  soil  the  wound;  (b)  that  air  enters  the  stom- 
ach, and  experience  has  shown  that  the  suction  of  air  into  the  stomach  during 
a  gastrectomy  is  very  dangerous,  and  that  for  some  obscure  reason  pulmonary 
troubles  are  liable  to  develop. 

Step  9.— To  the  stomach  stump  insert  a  row  of  lock  stitches  (Fig.  422). 
These  must  be  introduced  through  all  the  coats  of  the  stomach  and  pulled 


Fig.  422. — {Mayo,  from  sketches  by  the  author.) 


tight.  [As  an  alternative  method  Connell's  suture  may  be  employed.]  A 
second  row  may  be  introduced  as  an  additional  safeguard.  Remove  the  Kocher 
clamp.  Bury  the  closed  stomach  stump  by  a  row  of  continuous  Lembert  or 
Gushing  sutures,  reinforced,  if  necessary,  by  a  few  points  of  Lembert  sutures 
(Fig.  423). 

Step  10. — Perform  a  gastroenterostomy,  either  anterior  or  posterior,  by  tmit- 
ing  an  appropriate  portion  of  jejunum  to  the  lowest  part  of  the  remainder  of 
the  stomach,  with  button  or  suture  (Fig.  423). 

Step  II. — If  many  adhesions  have  been  separated,  especially  on  the  poste- 
rior wall  of  the  stomach,  introduce  either  a  cigarette  drain  or  a  split  rubber  tube 


328 


THE   STOMACH. 


containing  a  few  strands  of  gauze.  The  drain  is  rarely  required.  Close  the 
abdominal  wound. 

Moynihan's  Technic. — The  sequence  of  steps  in  the  operation  as  per- 
formed by  Moynihan  is  as  follows: 

The  belly  having  been  opened  and  parts  exposed. 

(a)  Divide  the  duodenum  between  crushing  clamps.  Catch  and  ligate 
vessels  individually.  Find  and  remove  the  subpyloric  (subduodenal)  lymph 
nodes  which  lie  near  the  second  part  of  the  duodenum. 

(b)  Divide,  between  ligatures,  the  gastro-colic  omentum. 

(c)  Divide,  between  ligatures,  the  gastro-hepatic  omentum  as  high  up  as 
possible.     Ligate  the  coronary  artery  late:  this  permits  access  to  it  at  a  high 


Fig.  423. 

level  and  gives  access  to  some  high  lymph  nodes  into  which  lymphatics  drain 
directly  from  the  pyloric  region.     Remove  the  nodes. 

(d)  Tear  a  hole  in  the  mesocolon  and  pull  a  loop  of  jejunum  through  it. 
Perform  posterior  gastro-enterostomy  using  the  cardiac  portion  of  the  stomach. 
The  anastomosis  is  more  easily  perfomed  before  rather  than  after  excising  the 
portion  of  stomach  to  be  removed. 

(e)  Choose  the  line  of  section  on  stomach.  Put  in  a  stay  or  traction  suture 
on  the  lesser  curvature  well  proximal  to  the  line  of  section.  Apply  a  clamp  to 
the  stomach  3/4  inch  proximal  to  the  line  of  section  and  distal  to  the  stay  suture 
which  forms  a  great  safety  if  the  clamp  slips. 


PARTIAL   GASTRECTOMY.  329 

(J)  Divide  the  stomach  with  the  cautery. 

(g)  Suture  the  mucosa  with  catgut.  Apply  two  layers  of  continuous  Lem- 
bert  (Gushing)  sutures,  after  removing  the  clamp. 

(A)  Fix  the  cut  edge  of  the  gastro-colic  omentum  to  the  lower  end  of  the 
stomach. 

(i)  Attend  to  the  duodenal  stump  in  the  usual  fashion  and  then  attach  it 
by  a  stitch  to  the  anterior  surface  of  the  pancreas. 

(j)  Pull  the  great  omentum  up  in  front  of  the  transverse  colon  and  tuck  it 
into  the  cavity  now  existing  above  the  colon. 

AJter-treatment. — The  special  rules  for  the  after-treatment  of  stomach  opera- 
tions are,  shortly,  as  follows: 

(a)  If  the  patient  is  much  dehydrated,  give  intravenous  or  subcutaneous 
infusions  of  saline  solutions.  These  may  be  repeated  during  a  few  days  if 
necessary.  If  not  dehydrated  and  if  stimulation  is  necessary,  administer  sub- 
cutaneously  a  20  per  cent,  solution  of  camphor  in  sterile  olive  oil.  As  the 
patient  leaves  the  operating-table  8  ounces  of  warm  coffee  should  be  given 
per  rectum.     Morphine  in  an  efficient  dose  may  be  administered  if  required. 

{b)  As  soon  as  the  effects  of  the  angesthetic  wear  off  (within  a  few  hours) 
raise  the  patient  into  a  sitting  or  rather  semi-sitting  posture.  This  tends  to 
obviate  pulmonary  disturbances  and  is  important. 

{c)  Twelve  hours  after  operation  small  doses  of  hot  water  may  be  given  by 
the  mouth ;  and  next  day,  if  there  is  no  nausea,  an  ounce  of  hot  water  may  be 
given  hourly. 

{d)  Nourishment  must  be  by  rectal  feeding  for  from  four  to  six  days 
after  operation,  when  fluid  food  may  be  given  by  the  mouth.  After  thirty- 
six  hours',  experiments  with  small  quantities  of  predigested  liquid  food  may 
be  instituted.     See  footnote,  page  290. 

{e)     If  a  drain  has  been  used,  it  may  be  removed  about  the  sixth  day. 

Ultimate  results  of  resection  of  the  stomach  Jor  cancer. 

Out  of  ninety-four  cases  which  survived  three  years  or  longer  and  which 
were  without  recurrence  at  the  beginning  of  the  third  year  only  five  suffered 
from  later  recurrence.  Of  the  remaining  eighty-nine  cases  the  cures  had 
persisted  sixteen  years  in  one,  ten  years  in  five,  and  from  five  to  ten  years  in 
thirty-four.  The  hope  of  permanent  cure,  according  to  Leriche's  figures, 
is  about  20  per  cent.  [Leriche,  "Rev.de.  Med.,"  Feb.,  1906.  Ref.  "Zen- 
tralblatt  fiir  Chir.,"  1907,  No.  29.] 

The  Mayo's  statistics  of  partial  gastrectomies  and  pylorectomies  per- 
formed between  April,  1897,  and  January,  19 10,  are  as  follows: 

Number  of  operations  266  with  thirty-four  deaths  (12.4  percent.).  Forty- 
two  of  the  operations  were  not  for  cancer.  During  1909  there  were  forty- 
six  operations  with  four  deaths  (8.6  per  cent). 

Operations  for  carcinoma  involving  the  pyloric  end  of  the  stomach: 
Total  number,  224. 
Average  age,  ^z- 


330  THE   STOMACH. 

Patients  operated  on  over  five  years  ago: 

Total  number,  50. 

Present  condition  known,  39. 

Alive  and  well:  one  8  years,  2  1/2  months;  one  8  years;  one  7  years 
2,  months  (lias  since  died  of  recurrence);  one  6  years;  one  6  years, 
II  months;  one  5  years,  3  1/2  months;  one  5  years.     Total,  8. 

Patients  operated  on  over  four  years  ago: 

Total  number,  85. 

Present  condition  known,  64. 

Alive  and  well,  13. 
Patients  operated  on  over  three  years  ago: 

Total  number,  117. 

Present  condition  known,  88. 

Alive  and  well,  18. 
Patients  operated  on  less  than  three  years  ago: 

Total  number,  107. 


CHAPTER  XXXII. 
OPERATIONS  ON  THE  INTESTINES. 

Apart  from  operations  which  are  essentially  directed  against  the  biliary 
passages,  or  from  the  operation  of  gastro-duodenostomy,  the  only  lesion 
commonly  calling  for  interference  with  the  duodenum  is  ulceration.  Duo- 
denal ulceration  is  much  more  common  than  is  usually  supposed.  The 
operative  treatment  depends  on  the  presence  or  absence  of  perforation. 

Perforation  of  the  Duodenum, — The  ulcer  is  almost  invariably  situated 
in  the  first  2  1,2  inches  of  the  gut,  and  is,  therefore,  accessible. 

Step  I. — Open  the  abdomen  by  the  right  rectus  incision.  Guided  by 
evidences  of  inflammation  and  by  anatomical  knowledge,  expose  the  disease. 

Step  2. — Cleanse  the  affected  area.  Protect  the  rest  of  the  belly  with 
gauze.  If  possible,  close  the  perforations  by  Lembert  sutures.  Reinforce 
the  suture  by  an  omental  graft.  If  possible  make  the  line  of  suture  trans- 
verse to  the  long  axis  of  the  bowel;  this  to  avoid  stricture.  In  one  case  H.  S. 
Clogg  ("Brit.  Med.  Jour.,"  Jan.  2,  1905),  unable  to  close  the  perforation  by 
sutures,  brought  up  the  free  edge  of  the  omentum  and  stitched  it  around 
the  perforation  with  excellent  effect.  Murphy  writes:  "Where  the  intestinal 
wall  is  indurated  and  adherent  to  neighboring  tissues  it  must  be  sufficiently 
liberated  and  freed  to  admit  of  an  easy  apposition  of  its  convex  surfaces 
with  two  rows  of  suture.  The  failure  to  free  the  intestine  from  neighboring 
structures  is  the  most  common  cause  of  failure  of  union." 

Step  3. — Provide  for  drainage  through  the  primary  incision;  through  a 
special  opening  made  in  the  right  loin  just  below  the  last  rib,  or  when  there 
is  much  pentonitis,  provide  pelvic  drainage  through  an  anterior  wound  and 
keep  the  patient  in  the  Fowler  position. 

When  the  patient's  general  condition  is  good,  it  might  be  wise  to  follow 
Step  3  by  performing  a  gastro-enterostomy  so  as  to  give  rest  to  the  duodenum 
and  permit  healing  of  the  ulcer. 

Duodenal  Ulceration  without  Perforation. — The  treatment  of  ulcer- 
ation and  its  sequel,  stenosis,  is  gastro-enterostomy. 

Enterotomy  and  Closure  of  Intestinal  Perforations. — Enterotomy 
is  the  operation  performed  for  the  extraction  of  foreign  bodies  or  for  the  evacua- 
tion of  intestinal  contents  in  certain  cases  of  obstruction  where  enterostomy 
is  not  indicated.  As  the  closure  of  the  gut  after  incision  is  similar  to  the 
procedure  required  in  perforation,  the  two  subjects  may  be  treated  together. 

Step  I. — Expose  the  intestine  by  an  incision  in  or  near  the  median  line. 
Exceptionally  some  other  incision  is  preferable. 


332 


OPERATIONS    ON   THE   INTESTINES. 


Step  2. — Find  and  pull  out  of  the  belly  the  loop  of  gut  to  be  attacked. 
(If  the  case  is  one  of  perforation,  empty  the  loop  by  stripping  it  with  the  6ngers 
and  apply  clamps  or  their  equivalent.)  Protect  the  belly  cavity  with  pads. 
Slep  3. — Make  a  longitudinal  incision  through  the  intestinal  wall  on  the 
side  opposite  to  the  mesenteric  attachment.  Extract  the  foreign  body.  Un- 
doubtedly a  longitudinal  incision  when  closed  narrows  the  gut  lumen  more 

than  does  a  transverse,  but  the  amount  and 
danger  of  this  narrowing  have  been  much 
exaggerated  and  the  longitudinal  cut  is  the 
more  convenient  and  practical. 

Step  4. — Closure  of  the  intestinal  wound. 

(A)    If  the  opening  is  very  small,  one  or 

two  points  of  Lembert  sutures  will  suffice, 

or    a   purse-string    suture    may    be    better 

(Fig.   424). 

(B)  If  the  opening,  while  longer,  is 
linear,insert  a  row  of  continuous  through- 
and-through  sutures  for  hemostasis  and 
occlusion,  and  cover  these  by  a  line  of 
Lembert  sutures,  either  continuous  or  inter- 
rupted. Some  surgeons  do  not  use  the 
deep  row  of  sutures,  but  it  is  both  a  convenient  and  a  safe  procedure. 

(C)  If  the  opening  is  large,  or  so  contused  or  diseased  that  sutures  close 
to  it  will  not  hold,  direct  closure,  whether  transverse  or  longitudinal,  leads 
to  serious  obstruction  (Fig.  425).  The  effects  of  the  resulting  stenosis  may 
be  discounted  by  making  an  anastomosis  between  the  loop  of   gut  leading 


Fig.  424. — (Monod  and  Vanverts.) 


Fig.  425. — {Monod  and  Vanverts). 


to  and  that  going  from  the  stenosis,  or  the  injured  segment  of  intestine  may 
be  excised. 

Step  5. — Cleanse  the  exposed  gut.  Review  the  line  of  suture  reinforcing 
it,  where  necessary,  by  points  of  Lembert  sutures.  Remove  the  protective 
pads.     Replace  the  intestines  in  the  belly. 

Step  6. — Close  the  belly.     Apply  dressings. 

If  there  is  any  fear  that  the  intestinal  sutures  will  fail  to  do  their  duty, 
many,  probably  most,  surgeons  apply  a  wick  of  gauze  or  cigarette  drain  to 


LATERAL  ANASTOMOSIS. 


333 


the  wounded  gut,  bringing  the  free  end  of  the  drain  out  through  the  parietal 
wound.  To  the  writer  it  appears  that  such  a  precaution  is  liable  to  lead 
to  the  very  state  of  affairs  it  is  meant  to  prevent;  that  the  foreign  body  or  drain 
close  to  the  line  of  suture  may  possibly  interfere  with  the  process  of  repair. 

Lateral  Anastomosis  by  Means  of  Suture. — The  following  operation 
is  in  all  essentials  that  described  by  Abbe: 

Step  I. — Bring  outside  the  abdominal  cavity,  which  is  protected  by  gauze 
pads,  the  loops  of  gut  to  be  united.  Place 
the  loops  together  in  such  a  manner  that 
about  five  inches  lie  in  contact.  Squeeze 
the  contents  out  of  the  loops  and  apply 
suitable  clamps  to  keep  them  empty. 

Step  2. — Unite  the  two  loops  of  gut  for 
about  four  inches  by  a  row  of  continuous 


Fig.  426.  Fig.  427. 

suture  (continuous  Lembert),  parallel  to  and  not  far  from  the  mesenteric 
border.  The  stitches  involve  the  serous,  muscular,  and  fibrous  or  sub-mucous 
tunics.     Fasten  the  suture  with  a  knot  (Fig.  426). 

Step  3. — At  a  safe  distance  from  the  line  of  suture  A,  B,  make  the  opening 
X,  Y,  in  one  of  the  loops.  The  opening  must  be  about  one  inch  sliorter 
than  the  line  of  suture  A,  B.     A  portion  of  intestinal  wall  about  one-half  inch 


334 


OPERATIONS    ON    THE   INTESTINES. 


in  width  may  be  excised  along  the  Hne  of  the  opening  X,  Y.  This,  however, 
is  optional.  Seize  any  bleeding  points  with  forceps.  Repeat  Step  3  on  the 
other  loop  of  gut. 

Step  4. — With  a  continuous  catgut  suture  unite  the  corresponding  edges 
of  the  openings  in  the  two  loops  of  gut  (Fig.  427).  This  continuous  suture 
involves  all  the  coats  of  the  intestine  and  shuts  ofif  the  intestinal  cavity  from 
the  line  of  Lembert  sutures;  at  the  same  time  it  prevents  loss  of  blood.  The 
suture  may  be  applied  in  the  Connell  fashion. 


4 


Fig.  428. 


Step  5. — Continue  the  line  of  suture  A,  B  (posterior  row  of  Lembert 
suture)  completely  around  the  site  of  the  anastomosis  (Fig.  427,  L,  L,  L), 
thus  entirely  burying  from  view  the  occlusion  or  hemostatic  sutures  intro- 
duced in  Step  4.  Fig.  428  shows  the  last  of  these  sutures  being  introduced 
in  the  interrupted  fashion.  The  continuous  suture  is  as  good  as,  or  really 
better  than,  the  interrupted. 

Step  6. — Review  the  line  of  suture  and  if  necessary  reinforce  it  by  a  few 
extra  stitches.     Fig.  429  shows  a  sectional  view  of  the  anastomosis. 


LATERAL   ANASTOMOSIS. 


335 


Step    7. — Remove    the    intestinal    clamps.     Clean    the    wound.     Remove 
gauze  pads.     Return  the  intestines.     Close  the  abdominal  wound. 

Dr.  Charles  T.  Parkes  recommended  a  smaller  opening  in  the  gut  than 


Fig.  429. 


that  described  above.  After  making  a  longi- 
tudinal incision  through  the  intestinal  wall 
at  a  point  opposite  the  mesenteric  attach- 
ment, he  made  a  short  transverse  incision 
at  either  end  of  it  and  so  formed  two  flaps 
of  gut-wall  which  he  turned  inwards,  fasten- 
ing them  in  this  position  by  a  few  sutures. 
The  turning-in  of  the  flaps  prevented  con- 
traction of  the  anastomotic  openings.  After 
making  the  openings  in  the  opposing  loops 
of  gut.  Parks  completed  the  union  by  a 
single  row  of  continuous  Lembert  sutures, 
each  stitch  involving  one-third  inch  of  in- 
testinal wall,  the  stitches  being  one-eight  of 
an  inch  apar^. 

"It  makes  no  difference  whatever  what 
kind  of  suture  is  used,  so  that  the  principle 
of  postively  securing  the  application  of  two 
broad  surfaces  of  peritoneum  in  contact 
with  each  other  is  certainly  carried  out." 
(Parkes.) 

Fig.  430  shows  how  the  Abbe  operation 
may  be  more  conveniently  performed  with 
the  aid  of  two  gastro-enterostomy  clamps. 
The  clamps  used  as  in  the  diagram  simplify 
the  operation  amazingly,  hold  the  segments  of 
gut  in  convenient  position,  prevent  bleeding 
and  prevent  escape  of  intestinal  contents. 


Fig.  430. — -L.xTERAL  Anastomosis. 
Clamps  in  place.  Posterior  row 
serous  sutures  in  place.  Gut  incised; 
through-and-through  or  Connell  suture 
begun.  When  the  through-and- 
through  suture  is  in  place  completly 
around  the  anastomotic  opening,  re- 
move the  clamps  and  then  insert  the 
anterior  row  of  serous  sutures.  In 
this  diagram  it  is  assumed  that  a  por- 
tion of  gut  has  been  excised;  that  both 
afferent  and  efferent  loops  have  been 
closed.  M.S.  indicates  the  line  of 
union  of  the  esentery  of  the  two  loops 
of  the  gut.  No  holes  must  be  left  in 
the  mesentery. 


33^ 


OPERATIONS    ON   THE   INTESTINES. 


Lateral  Anastomosis  by  Means  of  the  Murphy  Button. — Step  i. — 
Having  opened  the  belly,  pull  the  two  loops  of  gut  which  it  is  desired  to  unite 
out  from  the  abdominal  cavity  and  protect  the  latter  with  gauze  pads.  Empty 
the  segments  of  intestine  and  keep  them  empty  by  means  of  clamps. 

Step  2. — Introduce  a  purse-string  suture  of  fairly  stout  silk  or  catgut  into 


Fig.  431.  Fig.  432. 

Figs.  431  and  432. — {Monod  and  Vanverts.) 

the  gut  opposite  its  mesenteric  attachment.  The  suture  pierces  all  the  coats 
of  the  gut.  Make  a  longitudinal  opening  into  the  gut,  large  enough  to  per- 
mit the  introduction  of  a  Murphy  button  of  appropriate  size.  This  cut  is  in 
the  area  surrounded  by  the  purse-string  suture  (Fig.  431). 

Step  3. — Seize  one  half  of  the  Murphy  button  with  hemostatic  forceps 
and  introduce  its  head  into  the  gut.     Weir  has  found  that  the  forceps  may 


Fi«-  433-  Fig.  434. 

Figs.  433  and  434. — {Monod  and  Vanverts.) 

so  injure  the  button  as  to  render  it  unsafe.  Dawbarn  plugs  the  two  segments 
of  the  button  with  corks,  thus  providing  handles  and  at  the  same  time  pre- 
venting escape  of  intestinal  contents.  Cordier  has  devised  ingenious  metal 
handles  to  plug  the   button  and   take  the  place  of  the  corks. 

Pull  the  purse-string  tight  and  tie  it  in  such  a  manner  that  the  opening 


MCGRAW,   ELASTIC   LIGATURE. 


337 


in  the  gut  is  snugly  fastened  around  the  neck  of  the  button  (Fig.  432).  With 
scissors  or  knife  remove  any  excess  of  tissue  distal  to  the  suture  which  might 
interfere  with  the  proper  approximation  of  the  two  halves  of  the  button. 

Repeat  Steps  2  and  3  on  the  other  loop  of  gut. 

Step  4. — Remove  the  hemostatic  forceps  or  corks  from  the  two  halves 
of  the  button.  Insert  the  neck  of  the  male  half  of  the  button  into  that  of  the 
female  half  and  push  them  together  firmly  (Figs.  433  and  434).  A  few  points 
of  Lembert  suture  may  be  used  to  reinforce  the  union. 

In  Step  2  the  incision  may  be  made  into  the  gut  before  the  purse-string 
suture  is  introduced.     A  good  method  of  applying  the  stitch  is  shown  in  Fig.  435, 

Anastomosis  by  Means  of  McGraw's  Elastic  Ligature. — Steps  i  and 
2  are  identical  with  the  operation  by  means  of  suture. 


Fig.  435. 

Step  3. — Thread  a  piece  of  well-rounded  elastic-cord,  about  3  mm.  in 
diameter,  in  a  straight  Hagedorn  needle.  (The  end  of  the  cord  is  tapered 
with  a  knife  to  permit  of  threading.)  Pass  the  needle  into  the  lumen  of  the 
gut  and  out  again  at  a  point  about  2  1/2  inches  distant.  The  track  of  the 
needle  corresponds  to  the  incision  made  into  the  gut  in  the  suture  operation. 
With  a  sharp  jerk  pull  the  needle  and  with  it  the  elastic  cord  through  the 
intestinal  walls.  The  assistant  keeps  the  cord  on  the  stretch  during  this 
manoeuvre.  Repeat  this  in  the  opposite  direction  on  the  other  loop  of  gut. 
Tighten  the  ligature  as  much  as  possible;  cross  its  ends  and  secure  them 
by  a  stout  silk  thread  passed  underneath  and  tied  on  top. 

Step  4. — Complete  the  line  of  continuous  Lembert  suture  around  the 
site  of  anastomosis  thus  entirely  hiding  the  elastic  ligature.  This  finishes 
the  intestinal  part  of  the  operation. 

The  elastic  cord  or  ligature  establishes  a  communication  between  the 
two  loops  of  gut  in  from  three  to  four  days.  By  its  use  dangers  of  soiling  the 
peritoneum  by  visceral  contents  escaping  during  the  operation  are  eliminated. 
In  the  hands  of  McGraw,  Willy  Meyer,  and  others  the  method  has  proved 
very  satisfactory. 


33^ 


OPERATIONS    ON   THE   INTESTINES. 


End-to-end  Anastomosis;  Circular  Enterorrhaphy. — In  making  an 
end-to-end  anastomosis,  whether  by  means  of  suture  or  the  Murphy  button, 
it  is  of  prime  importance  to  understand  the  anatomy  of  the  mesenteric  inser- 
tion. When  the  mesentery  approaches  the  gut,  its  two  peritoneal  surfaces 
separate  to  surround  the  intestine  and  leave  a  /\-shaped  space  loosely 
filled  with  fat  and  containing  the  vessels  going  to  or  from  the  gut.  Opposite 
this  space  the  muscular  tunics  lie  uncovered  by  peritoneum.     The  most  im- 


FlG.  437. 


•""-^ 


portant  stitch  in  circular  enterorrhapy  is  that  which  closes  this  space.  The 
author  has  frequently  operated  with  satisfaction  in  the  following  manner: 
Step  I. — Bring  the  divided  ends  of  the  two  segments  of  gut  together  out- 
side the  belly  cavity.  Unite  them  by  a  stitch  of  sUk  or  catgut  at  a  point  be- 
side the  mesenteric  attachment,  at  a  point  on  the  free  edge,  and  at  a  point 
midway  between  these  two  (Fig.  436).  These  three  stitches  insure  uni- 
formity in  suturing.  The  same  end  may  be  attained  by  the  use  of  miniature 
volsella.  With  a  continuous  suture,  involving  all  the  coats  of  the  gut,  com- 
plete the  union  of  the  two  segments  (Fig.  437). 
This  suture  stops  bleeding  and  prevents  contamina- 
tion of  the  next  or  essential  row  of  sutures  by  the 
intestinal  contents. 

Step  2. — At  the  mesenteric  attachment  introduce 
a  Mitchell-Hunner  mesenteric  mattress  suture  (Fig. 
438),  involving  the  serous,  muscular,  and  submucous 
tunics.  To  secure  serous  apposition  at  the  mesen- 
teric space  there  is  no  suture  comparable  to  the 
above.  The  suture  shown  in  Fig.  439  is  less 
desirable. 

Step  3. — Introduce  a  Lembert  suture  at  the  free 
margin  of  the  gut  opposite  the  mesenteric  attach- 
ment. Introduce  a  continuous  Lembert  suture  all  around  the  gut.  Each 
stitch  should  pick  up  about  1/3  inch  of  the  serous  and  subjacent  muscular 
tunics.  Do  not  pull  the  stitches  very  tight;  all  that  is  required  is  that 
serous  coat   should   be  kept  in  touch  with  serous   coat   (Fig.   440). 

Step  4. — Review  the  wound.  Wliere  advisable  reinforce  the  line  of  union 
with  Lembert  sutures.  Beware,  however,  of  causing  too  much  invagination 
of  the  wound  and  thus  producing  stenosis. 


Fig.  438. — Mitchell- 
Hunner  Stitch. 


INTESTINAL  ANASTOMOSIS. 


339 


The  late  Dr.  Chas.  T.  Parkes  made  use  of  the  contmuous  Lembert  suture 
in  the  manner  described,  but  omitted  the  provisional  suture  which  penetrates 
all  the  coats  of  the  gut.  Parkes  writes,  apropos  of  his  experimental  work: 
"The  greatest  number  of  mishaps  followed  drawing  the  sutures  too  tightly, 


Fig.  439. 


Fig.   440, 


which,  if  done,  leads  to  death  of  the  applied  edges,  and,  of  course,  to  failure. 
They  must  be  drawn  only  sufficiently  close  to  bring  the  surfaces  fairly  in 
contact;  the  subsequent  swelling  from  obstructed  circulation  will  hold  the 


Fig.  441. 


Fig.  442. 


surfaces  firmly  together  until  glued  to  each  other  by  the  rapidly  forming  adhesive 
material." 

End-to-end  anastomosis  is  most  easily  performed  with  the  aid  of  clamps. 
Doyen's  hysterectomy  clamps,  with  rubber  tubing  over  the  blades,  are  most 
convenient. 


340 


OPERATIONS  ON  THE  INTESTINES. 


Step  I. — Clamp  each  of  the  segments  of  gut  about  one  inch  from  their 
open  ends.     Place  the  clamps  and  contained  gut  side  by  side  (Fig.  441). 

Step  2. — Introduce  the  posterior  row  of  continuous  Lembert  sutures  (AB, 
Fig.  441). 

Step  3. — Beginning  at  the  mesenteric  attachment,  introduce  a  Conn  ell 
suture  (Figs.  441  and  442)   completely  around  the  gut,  closing  it  entirely. 

Step    4. — Complete    the    introduction    of    the 
continuous   Lembert   suture  (AB,  Fig.  443). 
Step  5. — Close  the  rent  in  the  mesentery. 
Maunsell's    Operation. — A    portion    of    gut   is 
supposed  to  have  been  excised. 

Step  I. — Unite  the  severed  ends  of  the  gut  by 
two  sutures  involving  the  whole  thickness  of  the 
intestinal  wall.  One  suture  is  inserted  near  the 
mesentery,  the  other  on  the  opposite  side  of  the 
intestine.     The  ends  of  both  sutures  are  left  long 

(Fig.  444)- 

Step  2. — On  the  free  margin  of  the  larger  segment  of  gut  (Fig.  445)  make 
the  longitudinal  cut  "a"  at  least  one  inch  from  the  point  of  insertion  of  sutures. 

Step  3. — With  an  eyed  probe  push  the  long  sutures  through  the  lumen 
of  the  gut  and  out  of  the  cut  "a."  Pull  upon  the  threads  until  the  divided 
ends  of  the  gut  emerge  through  the  opening  "a."  Looking  at  the  double 
tube  of  gut  protruding  through  the  opening  "a"  note  that  their  peritoneal 
surfaces  are  in  contact  (Fig.  446). 


Fig.  443. 


Fig.  445.  Fig.  446. 

Figs.  444,  445,  446,  447. — (Maylard.) 


i^*m^ 


Fig.  447. 


Step  4. — Pass  a  straight,  fine  seamstress'  needle  through  the  protruded  tube 
of  gut  and  thus  introduce  about  ten  sutures  of  fine  horse-hair  or  silkworm-gut. 
The  sutures  should  be  inserted  about  1/4  of  an  inch  from  the  cut  edge  of  gut. 
Pick  up  the  sutures  as  they  pass  through  the  lumen  of  the  gut  and  divide 
them,  thus  obtaining  twenty  sutures  in  in  position  instead  of  ten.  Tie  the 
sutures.  lodoformize  the  line  of  stitches.  Cut  short  the  temporary  stitches. 
Pull  the  protruded  portion  of  bowel  back  into  its  normal  position. 


MURPHY  S    BUTTON. 


341 


Step  5. — Close  the  wound  "a"  by  appropriate  sutures.  Repair  the  mes- 
entery (Fig.  447). 

End-to-end  Union  by  means  of  the  Murphy  Button. — This  operation 
is  practically  the  same  as  that  described  for  lateral  anastomosis.  The  only 
point  to  be  specially  noticed  is  the  method  of  closing  the  mesenteric  space  or 


Fig.  448. 


Fig.  449. 


Fig.  4S0. 
Figs.  448,  449  450. — {Da  Costa.) 


insertion  with  the  purse-string  suture.     Figs.  435,  448,  449,  450  explain  them- 
selves. 

An  endless  number  of  contrivances — decalcified  bone  plates  and  bobbins, 
rawhide  plates,  catgut  rings,  segmented  rubber  rings,  vegetable  plates,  etc. — 
have  been  invented  to  simplify  intestinal  anastomosis,  but  most  have  been 
discarded  as  cumbersome  and  unnecessary.     The  same  may  be  said  of  nu- 


342 


OPERATIONS    ON   THE   INTESTINES. 


merous  devices  to  support  or  distend  the  lumen  of  the  gut  while  stitches  are 
being  inserted. 

Of  these,  Harrington's  segmented  metal  ring  is  probably  by  far  the  best. 
(See  "Trans.  Am.  Surg.  Assoc,"  vol.  xxii.) 

The  operation  of  lateral  implantation,  i.  e.,  where  the  end  of  one  segment 


Fig.  451. 


Fig. 


452 


of  gut  is  anastomosed  to  the  side  of  another,  is  a  combination  of  end-to-end 
and  of  lateral  anastomoses,  and  is  sufficiently  explained  by  Figs.  451  and  452. 
Figs.  453  to  457  show  a  number  of  varieties  of  intestinal  anastomosis  and  im- 
plantation. 

ConneWs  method  of  enterorrhaphy  is  similar  to  Maunsell's  in  that  the  sutures 


Fig.  453. 


Fig.  454. 


Fig.  455. 


penetrate  the  whole  thickness  of  the  gut-wall,  and  differs  from  it  in  the  ab- 
sence of  the  second  incision  into  the  gut. 

Step  I. — ^Place  the  ends  of  the  gut  in  apposition,  with  the  mesenteric  attach- 
ment of  one  side  corresponding  to  that  of  the  other.  Introduce  two  or  more 
fixation  sutures,  F  (Fig.  458),  to  insure  accuracy  and  uniformity  in  stitching. 


CONNELL  S    SUTURE. 


343 


Instead  of  fixation  sutures,  miniature  volsella  may  be  employed.  Introduce 
the  continuous  suture  (S)  as  shown  in  Fig.  458.  In  this  manner  fully  two- 
thirds  or  even  three-fourths  of  the  circumference  of  the  gut  may  be  united. 
The  remaining  third  or  fourth  of  the  wound  is  not  so  simply  united,  but  if 
Fig.  459  is  carefully  studied,  the  method  will  be  clearly  understood.     When 


v^y 


Fig.  456. 


Fig.  457. 


Fig.  458. 


Fig.  459. 


the  two  portions  of  gut  are  united  and  the  suture  pulled  sufliciently  tight,  the 
two  ends  of  the  suture  T,  S,  emerge  at  the  same  point  (Fig:  460,  x). 

Step  2. — Introduce  through  the  line  of  suture  at  the  point  Y  (Fig.  460)  a 
threaded  needle.  Make  the  eye-end  of  the  needle  emerge  alongside  the  sutures 
T  and  S,  at  the  point  x.  Pass  the  ends  of  T  and  S  through  the  loop  of  the 
thread  in  the  needle  and  with  the  needle  pull  them  out  through  the  point  Y. 


344 


OPERA. IO>,S    ON    THE    INTESTINES. 


Step  3. — Slight  traction  on  T  and  S  will  bring  the  mucous  surface  of  the  gut 
at  the  point  x  into  contact  with  the  mucous  surface  at  the  point  Y  (Fig.  461). 
If  now  the  sutures  T  and  S  are  tied  tightly  together  and  the  knot  allowed  to  slip 
through  the  line  of  union  at  the  point  Y,  this  will  sufficiently  fasten  the  sutures. 
The  student  is  strongly  advised  to  familiarize  himself  thoroughly  with  this 
method  before  attempting  it  on  the  living.  An  old  coat  makes  a  good  model 
on  which  to  practise  this  operation.  Imagine  the  wrist  ends  of  the  sleeves 
to  be  open  ends  of  gut  and  unite  them.  A  few  minutes  of  such  practice  with 
a  coarse  needle  and  thread  makes  easy  the  comprehension  of  this  rather  puzzl- 
ing stitch. 

Remarks  on  Anastomosis. — In  the  preceding  pages  many  methods  have 
been  described  by  which  union  between  various  segments  of  the  gastro-intes- 
tinal  canal  may  be  effected  for  various  purposes.  The  experienced  surgeon 
has  no  difficulty  in  making  a  selection  of  the  method  which  will  serve  his  pur- 


FlG.  460. 


Fig.  461. 


pose  best;  a  hint  suffices  to  equip  him  for  the  performance  of  some  modified 
operation  with  the  details  of  which  he  was  not  previously  familiar.  With  the 
beginner  in  operative  surgery  it  is  entirely  different.  He  ought  to  select  a 
general  method  of  operating  suitable  for  almost  all  cases,  he  ought  to  practise 
this  method  ad  nauseam  on  intestines  removed  from  hogs  (vivisection  is  here 
unnecessary)  until  he  almost  can  carry  out  the  minutest  details  with  his  eyes 
blindfolded.  Having  once  established  for  himself  a  basal  or  normal  method 
of  operating,  excursions  into  the  more  refined  elegancies  of  technic  become 
easy  and  often  desirable. 

Lateral  anastomosis  is  the  most  universally  applicable  method  of  uniting 
one  segment  of  gut  to  the  other.  It  is  the  basal  method  of  operating  and  must 
be  mastered  in  every  detail  by  the  surgeon  before  he  presumes  to  open  the  ab- 
domen for  any  purpose,  as  in  the  course  of  the  simplest  of  intra-abdominal 
operations  circumstances  may  arise  which  compel  interference  with  the  in- 
testinal canal. 


ENTERECTOMY.  345 

The  following  operations  are  either  identical  or  almost  identical  with  lateral 
anastomosis: 

A.  Gastro- gastrostomy  in  Hour-glass  Stomach. — (a)  Union  of  the  two 
stomach  pouches  by  a  moderate-sized  opening.  (Identical  with  lateral  anas- 
tomosis.) (b)  Union  of  the  two  pouches  with  restoration  of  the  normal  shape 
of  the  stomach.  This  procedure  is  practically  the  same  as  Finney's  operation. 
(Almost  identical  with  lateral  anastomosis.) 

B.  Finney^ s  Operation. — Gastro-duodenostomy.  (Almost  identical  with 
lateral  anastomosis.) 

C.  Gastro-enterostomy. — (Identical  with  lateral  anastomosis.) 

D .  Cholecystenter ostomy. — (Identical 
with  lateral  anastomosis.) 

E.  En'ero  -  enterostomy.  —  L  a  te  r  a  1 
anastomosis — indicated  after  excision 
of  gut  {e.  g.,  in  gangrenous  hernia, 
tumor,  etc.)  or  for  purposes  of  intestinal 
exclusion. 

F.  Entero-colostomy . — Lateral  anas- 
tomosis. M^Clamp  y^CJamp. 

G.  Monari's  uretero-ureter ostomy  is 
practically  identical  with  lateral  anasto- 
mosis. 

Resection  of  a  Portion  of  Small  Intestine. — The  indications  for  this 
operation  are  localized  malignant  or  benign  tumors;  localized  tuberculous 
lesions;  gangrene;  trauma  extensive  enough  to  contraindicate  local  suturing, 
etc. 

The  Operation. — Step  i. — Open  the  belly  in  the  middle  line. 

Step  2. — Pull  the  afifected  loop  of  gut  outside  the  belly  and  protect  the  perit- 
oneal cavity  with  gauze  pads. 

Step  3. — Empty  the  contents  from  the  intestinal  loop  by  "stripping"  with 
the  fingers.     Apply  clamps. 

Step  4. — Note  the  blood-supply  as  it  passes  through  the  mesentery.  Ligate 
the  vesse's  supplying  the  portion  of  gut  to  be  removed. 

Step  5. — Divide  the  intestine  on  each  side  of  the  disease  at  a  point  where 
it  is  well  supplied  with  blood  (Fig.  462).  Section  of  the  gut  should  be  made 
obliquely,  more  of  the  free  border  being  removed  than  of  the  mesenteric.  This 
is  done — (a)  because  when  obliquely  divided  the  open  ends  of  gut  have  a 
greater  circumference  than  when  cut  transversely,  and  hence  allow  for  the  loss 
of  diameter  occasioned  by  suturing;  [b)  because  the  gut-wall  on  the  non-attached 
border  is  more  liable  to  be  well  nourished.  If  desirable,  excise  a  V-shapcd 
portion  of  mesentery  corresponding  to  the  segment  of  gut  removed. 

Step  6. — Either  unite  the  ends  of  the  gut  by  an  end-to-end  anastomosis  or 
close  them  by  means  of  suture,  preferably  purse-string,  and  provide  lor  intes- 
tinal continuity  by  a  lateral  anastomosis. 


346 


OPERATIONS    ON   THE   INTESTINES. 


Step  7. — If  a  V-shaped  portion  of  mesentery  has  been  removed,  unite  its 
edges  by  suture.  If  this  has  not  been  done,  fold  any  redundancy  upon  itself 
and  secure  by  a  few  stitches,  being  careful  not  to  interfere  with  the  nutrition 
of  the  gut. 

Step  8.— Review  the  wound.  Cleanse.  Remove  gauze  pads.  Return  the 
gut  into  the  belly.     Close  the  abdomen. 

Caecectomy  is  indicated  in  cases  of  malignant  or  tuberculous  disease,  as 
well  as  in  some  cases  of  intussusception. 

Step  I. — Open  abdomen  in  right  semilunar 
line;  expose  and  examine  the  diseased  organs. 

Step  2. — Incise  the  posterior  parietal  perito- 
neum at  the  outer  side  of  the  caecum  and  ascend- 
ing colon.  Free  the  caecum  from  its  bed  by  finger 
dissection.  Ligate  and  divide  the  branches  of 
the  ileocolic  artery  to  the  necessary  extent.  Com- 
pletely mobilize  the  diseased  segment  of  gut. 
The  caecum  may  be  so  mobile,  i.  e.,  so  well  pro- 
vided with  mesocaecum,  that  ligatures  or  clamps 
may  be  applied  directly  without  preliminary  dis- 
section. 

Step  3. — Treat  the  mobilized  gut  as  in  Paul's 
colectomy  (and  this  is  the  safer  plan),  or  proceed 
as  follows: 

With  two  crushing  forceps  applied  about  i  inch 
apart  strongly  clamp  the  ileum  at  a  point  6  to  8 
inches  above  the  caecum.  Divide  the  gut  between 
the  forceps.     Cleanse  the  cut  surfaces. 

Treatment  of  the  proximal  segment  of  the 
ileum:  (a)  With  a  continuous  suture  tightly 
close  the  open  end  of  the  gut  (i.  e.,  distal  to  the 
clamp);  {b)  surround  the  gut  about  i  1/2  inches 
proximal  to  the  clamp  with  a  purse-string  suture; 
(c)  remove  the  clamp;  invaginate  the  sutured  end  of  the  gut  and  tighten 
the  purse-string  sutures.  In  the  same  manner  with  crushing  forceps  doubly 
clamp  and  divide  the  ascending  colon  distal  to  the  disease.  Remove 
the  diseased  segment  of  gut.  Treat  the  distal  segment  of  colon  in  the  same 
manner  as  the  ileum. 

Make  a  lateral  anastomosis  between  the  ileum  and  the  colon  or  sigmoid. 
Repair  the  wound  in  the  peritoneum  (peritonealization)  (Fig.  463).  To 
do  this  it  may  be  necessary  to  mobilize  the  parietal  peritoneum  on  both  sides 
of  the  raw  surface  left  by  the  removal  of  the  caecum.  Unless  the  peritoneum 
is  mobilized  and  freed  from  the  ureter  when  sutures  are  inserted  and  tied, 
the  ureter  may  be  kinked. 

Jamison  and  Dobson  ("Lancet,"  April  27,  1907)  have  made  a  very  thorough 


Fig.  463. — Ileum  Anastomosed 
TO  Ascending  Colon. 
Peritonealization    of    wound. 
Divided  ends  of  ileum  and  colon 
closed. 


C^CECTOMY. 


547 


study  of  the  lymphatic  system  of  the  caecum,  and  as  a  result  recommend  the 
following  operation  for  the  removal  of  a  cancerous  caecum. 

Step  I. — Open  the  abdomen  in  the  right  semilunar  line  or  through  the  rectus 
muscle.     Push  the  omentum  and  small  intestine  to  the  left. 

Step  2. — Identify  the  lower  border  of  the  third  part  of  the  duodenum  and 
open  the  posterior  parietal  peritoneum  just  below  it.  Search  for  and  identify 
the  ileocolic  vessels  (Fig.  464). 

Wipe  downwards  the  fatty  tissue  surrounding  the  vessels,  taking  great  care 
not  to  wound  the  duodenum.  Doubly  ligate  and  divide  the  vessels  about  i 
inch  below  their  junction  with  the  superior  mesenteries.  This  devascularizes 
the  whole  ascendina;  colon. 


Duodenum 

a.  Colica  dextra. 


a.  Colica. 
Ileo-colica 


Peritoneum 


Ileum 


Fig.  464. 

Step  3. — Select  the  point  for  dividing  "the  colon  at  the  hepatic  flexure  or  on 
the  transverse  colon,  but  do  not  yet  divide  the  gut.  From  the  duodenum  to 
the  selected  point  on  the  colon  divide  the  peritoneum.  At  this  time  some 
branches  of  the  mid-colic  vessels  will  require  attention. 

Expose  the  course  of  the  ileocolic  vessels  down  to  the  caecum  and  appendix 
by  incising  the  peritoneum.  With  gauze  wipe  these  vessels  and  the  accom- 
panying chain  of  glands  and  fatty  tissue,  as  well  at  the  overlying  peritoneum, 
down  to  the  ileum  and  caecum  and  out  to  the  ascending  colon.  Identify  and 
avoid  the  ureter.  This  dissection  is  carried  so  far  that  the  caecum  and  colon  are 
completely  separated  from  the  body  except  where  they  are  continuous  with 
the  ileum  and  transverse  colon  and  where  they  are  united  to  the  body  by 
their  external  peritoneal  reflection.     Divide  this  peritoneal  reflection.* 

*  This  step  may  be  more  easily  accomplished  by  incising  the  peritoneum  external  to  the 
caecum,  mobilizing  the  gut  and  reaching  the  colic  arter}-  and  lymphatics  from  behind. 


348 


OPERATIONS    ON   THE   INTESTINES. 


Step  4. — Doubly  clamp  and  divide  the  colon  at  the  selected  spot.  Do  the 
same  to  the  ileum  about  6  inches  from  its  termination.  Close  the  open  end  of 
the  transverse  colon.  Close  the  open  end  of  the  ileum  and  make  a  lateral 
anastomosis  between  the  ileum  and  the  remaining  colon  or  the  sigmoid.  As 
an  alternative  method  the  open  end  of  the  ileum  may  be  anastomosed  to  the 
side  of  the  colon  or  sigmoid. 

Step  5. — By  means  of  judicious  suturing  with  catgut  cover  the  resulting 
raw  surfaces  with  peritoneum. 

Colectomy  (Sigmoidectomy). — A  diseased  portion  of  the  colon  may  be 
removed  in  the  same  manner  as  described  under  the  title  "Enterectomy." 

If  it  is  possible  to  bring  together  the  divided  ends 
of  the  gut  without  too  great  tension,  they  may  be 
united  by  means  of  suture  or  Murphy  button. 
As  a  rule,  such  end-to- end  union  is  impossible, 
and  one  must  content  one's  self  with  closing  the 
ends  of  the  gut  with  a  double  row  of  sutures  and 
establishing  an  anastomosis  between  a  suitable 
loop  of  small  intestine  and  the  colon  distal  to  the 
excision.  (See  foot-note  p.  350.)  If  the  caecum 
has  been  excised,  it  may  be  convenient  to  implant 
the  open  end  of  the  divided  small  intestine  into 
the  colon. 

Paul's  Colectomy  i.* — Make  a  free  incision 
through  the  parietes  over  the  part  of  the  colon  to 
be  removed. 

Step  2. — Ligate    and    divide    the    mesocolon 
sufficiently  to  free  the  gut  well  above  and  below  the  disease. 

Step  3. — Pull  the  freed  loop  of  gut  through  the  abdominal  wound.  Sew 
together  the  healthy  segments  of  gut  which  pass  through  the  abdominal  wound 
(Fig.  465).     Unite  the  cut  surfaces  of  mesocolon. 

Step  4. — Make  an  incision  into  the  prolapsed  gut  above  and  below  the  dis- 
ease.    Into  each  intestinal  opening  pass  a  glass  tube  and  ligate  it  there. 
Step  5. — Cut  away  the  diseased  portion  of  gut. 
Step  6. — Partially  close  the  abdominal  wound.     Apply  dressings. 
The  result  of  this  operation  is,  of  course,  a  faecal  fistula,  which  may  be 
closed  later. 

Enterectomy  in  two  stages  has  a  mortality  of  about  10  per  cent.,  while  that 
in  one  stage  (for  malignant  disease)  has  30  to  40  per  cent.  (v.  Mikulicz). 
In  about  30  per  cent,  there  is  no  recurrence  of  the  malignant  disease  after  four 
years.  The  operation  in  two  stages  may  be  employed  in  excision  of  the  lower 
end  of  the  ileum  with  or  without  excision  of  the  cecum. 


Fig.  465. — {Maylard.) 


*  A.  E.  Barker  strongly  recommends  an  oblique  incision  in  the  loin. 


DIVERTICULITIS.  349 

DIVERTICUTIS. 

The  papers  of  Cahier  ("Rev.  de  Chir.,"  September  19,  1906),  Brewer 
("Amer.  Journ.  Med.  Sc,"  October,  1907),  Mayo  ("Surg.  Gyn.  and  Obstet- 
rics," July,  1907)  and  others  have  attracted  attention  to  a  condition  named 
acquired  diverticulitis.  A  few  words  explanatory  of  the  disease  may  assist 
the  operator.  Acquired  or  false  diverticula  are  simple  herniae  of  the  mucous 
and  submucous  tunics  through  the  circular  muscular  coat  of  the  descending 
colon  and  sigmoid  at  points  where  the  musculosa  happens  to  be  weak.  Chronic 
leakage  may  take  place  through  the  diverticular  walls  and  give  rise  to  large 
inflammatory  deposits.  The  result  of  the  inflammation  may  be:  (i)  iVbscess. 
This  requires  free  drainage.  (2)  Acute  local  infection  plus  acute  obstruction. 
This  requires  free  drainage  plus  the  establishment  of  an  artificial  anus.  Sub- 
sequently, if  necessary,  the  diseased  segment  of  colon  may  be  excised.  (3) 
Chronic  obstruction  with  inflammatory  tumor  but  no  abscess.  This  form  is 
usually  mistaken  for  malignant  disease.  The  treatment  is  resection  of  the 
involved  segment  of  gut. 

Exclusion  or  Segregation  of  Intestine. — In  some  cases  where,  from 
extensive  adhesions  or  from  other  causes,  it  seems  impossible  or  improper  to 
excise  a  certain  segment  of  gut,  good  results  may  be  obtained  by  protecting 
it  from  the  irritations  incident  to  the  performance  of  its  physiological  functions. 
In  this  way  faecal  fistulae  may  be  induced  to  close  and  some  neoplasms  may 
develop  less  rapidly.  The  operation  which  is  used  for  this  purpose  may  be 
named  ^^ exclusion  of  the  intestine."  Tuberculous 
lesions  of  the  intestine,  unless  fairly  easy  of  excision, 
may  well  be  treated  by  exclusion. 

Arbuthnot  Lane  ("Brit.  Med.  Jour.,"  x-Vpril  i, 
1905)  highly  recommends  intestinal  exclusion  in 
cases  of  intractable  constipation  due  to  ptosis  of  the 
colon  and  chronic  adhesive  pericolitis.  He  divides 
the  ileum  about  8  inches  above  the  caecum,  closes  '       yig.  466. 

the  distal  end,  and  connects  the  proximal  either  with 
the  sigmoid  or  the  rectum.  Contrary  to  preconceived  notions,  this  operation  is 
not  followed  by  diarrhea.  A  similar  operation  seems  to  be  the  best  treatment 
for  idiopathic  dilatation  of  the  colon  (Hirschsprung's  disease).  It  must  be 
remembered,  however,  that  the  hugely  distended  sigmoid  colon  may  subse- 
quently give  rise  to  volvulus.  In  at  least  one  case,  even  after  much  of  the 
sigmoid  was  excised  for  volvulus,  the  remnant  of  sigmoid  between  the  anas- 
tomosis and  the  rectum  became  hugely  dilated  and  once  more  occasioned  vol- 
vulus. Mr.  Makins  corrected  the  position  of  the  loop  and  fixed  it  with  good 
effect  (Hawkins,  "Brit.  Med.  Journ.,"  March  2,  1907). 

In  the  following  description  it  is  assumed  that  the  caecum  and  adjacent 
segment  of  ileum  are  diseased  and  require  to  be  segregated. 


OPERATIONS    ON    THE    INTESTINES. 


(A)  Unilateral  Exclusion. — Step  i. — Open  the  abdomen  in  a  suitable  po- 
sition.    Examine  the  diseased  structures. 

Step  2. — Find,  empty,  and  doubly  clamp  the  afferent  segment  of  gut,  i.  e., 
the  portion  of  healthy  gut  which  passes  into  the  diseased  segment.  Divide 
the  gut  between  the  clamps.  Close  each  end  of  the  gut  by  a  row  of  through- 
and-through  sutures  covered  by  a  row  of  continuous  Lembert  sutures.  If 
desired,  the  purse-string  suture  may  be  employed  (Fig.  466,  X,  Y).* 

Step  3. — Make  an  anastomosis  between  the  afferent  loop  of  gut  and  the 
colon  in  a  suitable  place  (Fig.  466,  A). 

Step  4. — Close  the  abdomen. 

The  effect  of  unilateral  exclusion  is  that  while  the  contents  of  the  excluded 
segment  drain  into  the  colon,  no  material  from  the  ileum  passes  into  it — in 
fact,  a  short  circuit  is  established. 


M  JV 


Fig.  467. 


Fig.  468. 


(B)  Bilateral  Exclusion. — This  method  is  proper  only  when  a  iistula  leads 
from  the  skin  into  the  segment  to  be  excluded.  The  only  difference  between 
the  bilateral  and  the  unilateral  operation  consists  in  the  division  and  suture 
of  the  colon  distal  to  the  disease  and  proximal  to  the  anastomosis  (Fig.  467). 

(C)  Bilateral  Exclusion  with  Drainage  of  the  Excluded  Segment. — Here  no 
fistula  leads  into  the  diseased  segment.  The  operation  is  identical  with  that 
of  bilateral  exclusion  up  to  the  point  where  the  colon  is  divided.  Now,  instead 
of  closing  both  ends  of  the  colon  at  the  point  of  section,  only  the  distal  seg- 
ment is  closed  (Fig.  468,  N),  while  the  open  end  of  the  diseased  segment  is 
united  to  the  skin  and  permits  drainage  (Sk.). 

Vautrin  thinks  and  has  proved  that  drainage  from  one  end  of  the  excluded 
segment  of  gut  is  only  sufficient  if  the  disease  is  of  comparatively  limited  extent. 
Where  the  disease  is  extensive  and  the  gut  to  be  drained  is  more  or  less  coiled, 
then  both  ends  of  the  segregated  segment  should  be  united  to  the  skin  at  con- 
venient points;  if  necessary,  special  openings  being  made  through  the  belly- 
wall.  This  permits  of  thorough  drainage  and  lavage,  whereby  the  diseased 
gut  lumen  may  be  kept  clean  and  ulcerations  may  receive  local  treatment. 

*  Rutherford  Morison  has  shown  that  if  the  caecum  is  excluded  by  division  of  the  ascend- 
ing colon  and  mere  anastomosis  of  the  ileum  (without  complete  division  of  the  ileum)  to  the 
colon,  then  the  caecum  will  burst  unless  the  ileocaecal  valve  happens  to  be  incompetent.  The 
operation  seems  to  the  author  so  bad  that  the  warning  ought  to  be  unnecessary  but  the  accident 
has  happened. 


OBSTRUCTION.  35 1 

The  operation  of  "'  exclusion"  has  a  distinct  place  in  surgery,  and  in  America, 
at  least,  does  not  seem  to  have  received  sufficient  recognition. 

INTESTINAL  OBSTRUCTION. 

Whichever  form  of  obstruction  is  present  and  demands  operation,  there 
are  certain  points  common  to  the  treatment  of  all  of  them,  and  which  will  be 
considered  here. 

Before  assuming  that  true  obstruction  is  present  it  is  of  vast  moment  to 
examine  the  urine.  In  the  opinion  of  Paul  Delbet  ("LaPresse  Med.,"  Aug. 
24,  1907)  the  possible  existence  of  constipation  in  the  course  of  uremia  is  most 
important  because  if  one  considers  that  uremia  may  long  remain  latent;  that  it 
may  provoke  as  its  first  symptoms,  gastric  intolerance  with  vomiting  first 
alimentary  then  bilious;  that  there  may  be  a  subnormal  temperature  and  a 
slackening  of  pulse,  one  can  understand  that  constipation  accompanied  by 
these  symptoms  may  give  the  appearance  of  true  intestinal  obstruction  to  a 
complaint  which  is  entirely  non-surgical. 

As  a  matter  of  routine,  the  rectum  must  be  explored ;  the  omission  to  do  this 
has  too  often  led  the  surgeon  to  operate  unnecessarily  or  to  miss  the  aid  of  valu- 
able information  when  operating.*  There  is  often  not  much  time  in  which  to 
prepare  the  patient.  Enemata  will  almost  certainly  have  been  used  before  the 
question  of  operating  has  been  decided,  and  hence  the  lower  gut  is  empty.  It 
is  wise  to  clean  out  the  stomach  with  the  stomach-tube.  When  there  are  great 
nervousness  and  depression,  a  small  dose  of  morphine  has  a  quieting  and 
steadying  effect  which  outweighs  any  ill  which  it  may  do.  Usually  the  ab- 
domen is  opened  in  the  middle  line  below  the  umbilicus.  Through  this  open- 
ing any  obstruction  may  be  reached  and  treated. 

How  to  Find  the  Point  of  Obstruction. — Theoretically  one  might  proceed, 
as  is  usually  advised,  in  the  following  methodical  manner:  Pass  the  finger 
or  hand  into  the  right  iliac  region  and  palpate  the  caecum.  If  the  caecum  is 
distended,  pass  the  hand  along  the  colon,  as  the  obstruction  must  be  lower  down 
If  the  caecum  is  not  distended,  the  obstruction  must  be  in  the  small  intestine. 
Find  a  segment  of  gut  which  is  not  distended.  Trace  the  mesentery  of  the 
loop  of  gut  under  examination  to  its  origin  from  the  spine  and  find  which  is 
its  upper  surface.  Remember  that  the  right  layer  of  the  mesentery  is  also  its 
upper  layer.  Having  found  the  upper  or  right  surface  of  the  mesentery,  that 
portion  of  gut  which  goes  to  the  left  is  the  upper  segment,  and  if  followed  will 
assuredly  lead  to  the  point  of  obstruction.  Trace  the  gut  up  to  the  point  of 
obstruction,  but  do  not  let  the  intestines  come  out  of  the  belly  cavity. 

But  the  belly-walls  are  generally  tense,  the  intestines  are  ballooned  with 
gas,  the  transverse  colon  is  pushed  up  under  the  diaphragm,  and  to  carry  out 

♦Mackenzie  ("Brit.  Med.  Journ.,"  June  20,  igo6)  maintains  that  violent  pain  (peris- 
taltic) across  the  middle  of  the  abdomen,  not  below  the  umbilicus,  signifies  that  the  site  of  the 
obstruction  is  in  the  small  intestine  while  hypogastric  pain  means  that  it  is  in  some  part  of  the 
large  intestine. 


352  OPERATIONS    ON   THE   INTESTINES. 

the  methodical  examination  described  would  be  very  hazardous,  even  if  pos- 
sible. Greig  Smith  gives  excellent  advice  as  to  finding  the  obstruction.  He 
notes  that  wherever  the  obstruction  is  located  it  is  probable  that  the  most 
dilated  coils  will  rise  to  the  surface;  and,  the  greater  amount  of  bowel  being 
within  three  inches  of  the  umbilicus,  it  is  probable  that  the  most  dilated  coils 
will  be  within  sight.  Very  gently  move  the  coils  from  side  to  side  and  up  and 
down,  and  fix  on  the  most  dilated  coil,  which  will  be  at  the  same  time  the  most 
congested.  Follow  this  coil  in  the  direction  of  increasing  distention  and  con- 
gestion. "It  will  certainly  lead  to  the  stricture.  The  whole  manipulation 
may  be  carried  out  with  two  fingers."  If  this  method  fail,  Greig  Smith  rec- 
ommends to  let  the  most  distended  coil  escape  from  the  belly,  protected  by 
a  large  pad.  One  end  of  the  coil  escapes  less  readily  than  the  other  and  ap- 
pears more  congested ;  this  end  of  the  coil  will  lead  to  the  obstruction. 

When  the  intestines  are  very  much  distended  with  gas,  there  are  certain 
dangers  to  be  feared  and  combated  during  the  operation: 

1.  During  the  necessary  manipulations  the  pressure  of  the  fingers  or  hand 
may  cause  rupture  of  the  gut. 

2.  If  rupture  is  avoided  and  the  direct  cause  of  obstruction  relieved,  the 
ballooning  of  the  gut  may  cause  kinking  or  valve  formation  of  individual  loops 
and  so  prevent  emptying  of  the  bowel. 

3.  Prolonged  overdistention  so  paralyzes  or  weakens  the  intestinal  muscles 
that  they  are  unable  to  contract. 

4.  The  operation  being  completed,  it  may  be  impossible  to  close  the  abdom- 
inal wound  over  the  dilated  intestines. 

Greig  Smith  holds  that  "no  operation  for  intestinal  obstruction  is  properly 
completed  if  the  patient  leaves  the  operating-table  with  a  greatly  distended 
abdomen." 

Dahlgren  (" Centralblatt  f.  Chir.,"  April  15,  1905),  after  incising  the  intes- 
tine, "milks"  it  throughout  its  whole  length,  using  gloved  hands  or  a  special 
instrument  consisting  of  two  cylinders  like  bobbins  held  together  by  a  spring. 
This  he  finds  specially  useful  in  general  peritonitis  with  intestinal  paralysis. 
In  ileus  without  mechanical  obstruction  he  finds  atropin  sulphate  hypoder- 
mically,  i  milligramme  repeated,  of  great  value.  He  began  using  the  atropin 
without  faith  as  a  last  resort,  but  has  learned  its  value  (has  given  5  to  7  milli- 
grammes in  twelve  to  fifteen  hours). 

After  the  direct  cause  of  the  obstruction  has  been  located  and  treated,  or, 
if  more  convenient,  before  that  is  done,  permit  one  of  the  most  distended  loops 
of  gut  to  protrude  from  the  belly.  Protect  the  abdominal  cavity  with  hot  pads 
or  soft  towels.  Make  an  incision  into  the  gut  (either  transverse  of  longitudinal) 
and  encourage  its  contents  to  escape  into  a  suitable  vessel.  When  the  con- 
tents cease  to  escape,  clean  the  wound  and  close  it  with  a  continuous  Lembert 
suture.     If  necessary,  repeat  this  produre  on  other  distended  loops.*    A  prac- 

*  This  evacuation  is  by  no  means  always  required.  It  should  be  done  only  if  distention 
is  so  great  that  the  gut  will  probably  be  unable  to  empty  itself  in  the  natural  manner. 


INTUSSUSCEPTION. 


!53 


tical  detail  which  may  be  of  value  in  carrying  out  the  above  is  to  have  a  com- 
petent assistant  assigned  to  incise,  clean  and  close  the  gut,  and  that  for  his  work 
he  should  be  provided  with  instruments,  sutures,  and  sponges  entirely  separate 
from  those  used  by  the  operator.  The  object  of  this  detail  is,  of  course,  that 
the  operator  and  his  first  assistant  may  avoid  soiling  their  hands.  The  use 
of  rubber  gloves  which  can  be  changed  is  of  much  value. 

Before  closing  the  last  of  the  enterotomy  wounds  one  may,  through  it,  in- 
troduce into  the  gut  an  ounce  of  sulphate  of  magnesia  in  solution,  or  one 
may  inject  the  solution  into  the  gut  by  means  of  a  syringe  with  a  suitable  can- 
nula, subsequently  closing  the  puncture  with  one  or  more  stitches. 

If  the  patient  is  very  much  collapsed  or  if  it  is  difficult  to  find  and  treat  the 
direct  cause  of  the  obstruction,  the  surgeon  should  throw  aside  all  ambition 


Fig.  470. — (Guibe.} 

to  do  a  complete  operation  and  content  himself  with  bringing  the  most  distended 
coil  of  intestine  into  the  abdominal  wound  and  fixing  and  opening  it  there 
(enterostomy).  If  the  patient's  strength  is  equal  to  the  strain,  it  may  be  well 
to  precede  the  enterostomy  by  evacuating  the  gut  at  several  places  in  the  man- 
ner already  described,  as  the  intestine  may  refuse  to  empty  itself  through  one 
opening. 

Very  many  lives  have  been  saved  by  means  of  enterostomy  which  would 
have  been  sacrificed  had  a  more  complete  operation  been  attempted.  When 
sufficient  strength  has  been  gained,  the  patient  must  be  submitted  to  a  second 
and  radical  operation. 

Intussusception. — Open  the  abdomen.  Discover  the  site  of  the  obstruc- 
tion and  attempt  to  reduce  it. 

Reduction  of  the  Intussusception. — With  the  fingers  of  one  hand  gently  grasp 
the  entering  bowel  close  to  the  invagination;  with  the  other  hand  take  hold  of  the 
23 


354 


OPERATIONS    ON   THE   INTESTINES. 


bowel  immediately  below  the  intussusceptum  and  gently  press,  stroke,  coax,  or 
milk  the  intussusceptum  upwards.  Make  no  traction  or  massage.  If  reduction 
is  obtained,  examine  the  involved  gut  most  carefully,  lest  it  should  be  injured. 
If  an  elongation  of  the  mesentery  seems  to  have  had  anything  to  do  with  the 
production  of  the  intussusception,  it  is  easy  to  shorten  it  by  throwing  it  into 
folds  and  inserting  a  few  stitches.  If  this  is  done,  be  careful  not  to  interfere 
with  the  free  passage  of  blood  to  the  gut  through  the  mesentery.  If  reduction 
is  impossible,  and  it  frequently  is,  several  methods  of  treatment  are  possible: 

1.  Excision  of  the  portion  of  gut  involved.  The  operation  is  identical 
with  the  enterectomy  described  elsewhere,  and  is  only  permissible  when  the 
intussusception  is  limited  in  extent. 

2.  Excision  of  the  intussusceptum.  (Figs.  469,  470,  471,  472  explain  the 
operation  fully.) 


Fig.  471. — (Guibe.) 


Fig.  472. — (Guibe.) 


R.  C.  Coffey  in  a  remarkable  paper  on  intussusception  ("  Annals  of  Surgery," 
January,  1907)  recommends  the  following  operation:  After  exposing  the 
affected  gui  by  laparotomy  make  the  primary  incision  (Fig.  473)  into  the  intus- 
suscipiens.  Withdraw  the  intussusceptum  and  wrap  it  in  gauze  (Fig.  474). 
Pack  the  distal  end  of  the  intestine  with  gauze  (Fig.  474).  Cut  the  middle 
layer  of  the  intussusceptum  by  a  circular  incision  (Fig.  474) .  Catch  any  bleeding 
points  with  forceps  (Fig  474).  Doubly  clamp  and  divide  the  healthy  intestine 
(Fig.  474  and  Fig.  475).  Complete  the  primary  incision,  laying  open  the  dis- 
tal end  of  the  Ueum  and  freeing  the  intestine  to  be  removed  (Fig.  474).  Close 
the  distal  end  to  the  gut  with  sutures  (Fig.  475).  (Coffey  advises  making  this 
closure  only  partial  so  as  to  anastomose  the  proximal  segment  of  the  ileum 
to  it.  It  will  probably  be  better  to  close  the  gut  entirely  and  make  a  lateral 
anastomosis.)     Ligate  the  mesentery  (Fig.  475).     Divide    the  mesentery  and 


INTUSSUSCEPTION. 


(55 


remove  the  gangrenous  gut  (Fig.  475).  Close  the  proximal  end  of  the  ileum 
(Fig.  475).  Make  an  anastomosis  between  the  proximal  and  distal  segments 
of  ileum. 

K.  Israel  impressed  by  the  dangers  of  soiling  the  peritoneum  during  ex- 
cision first  delivers  the  intussuscipiens,  sutures  its  serous  coat  to  the  parietal 
peritoneum,  then  opens  it  and  excises  the  intussusceptum  as  above.  He  advises 
this  method  in  all  types  of  intestinal  stricture  producing  a  temporary  artificial 
intussusception  as  in  Maunsell's  operation. 


Fig.  473. — {Cofjey,  Annals  of  Surgery.) 


3.  Ellsworth  Eliot,  Jr.,  suggests  that  the  affected  portion  of  gut  be  brought 
near  the  abdominal  wound;  a  small  incision  (O)  be  made  near  the  end  of  the 
intussusceptum  through  the  gut  wall  just  below  the  lesion;  a  soft  catheter  (T) 
be  passed  through  this  wound  and  through  the  canal  of  the  intussusceptum  into 
the  gut  above;  the  incised  gut  be  sutured  to  the  parietal  wound  (W)  (Fig. 
476).  The  result  is  an  artificial  anus  below  the  obstruction,  preventing  increase 
of  the  intussusception  and  providing  intestinal  drainage  through  the  catheter. 
Eliot  thinks  the  method  may  be  of  use  in  the  case  of  young  children.  It  is 
only  mentioned  here  as  a  suggestion. 

4.  Instead  of  enterectomy,  the  operation  of  segregation  may  be  employed, 


25(> 


OPERATIONS    ON    THE    INTESTINES. 


;  Primary  Incision 


Fig.  474.-2.  Intussusception  withdrawn.  3.  Pack  in  distal  end  gut.  4.  Circular  in- 
cision of  middle  layer  intussusceptum.  5.  Forceps  on  vessels.  6,  7.  Ileum  divided  between 
clamps.     8,  Completion  of  primary  incision. — {Cofjey,  Annals  of  Surgery.) 


0/5T/IL  £m  or  /i£UM 
3 


to        II 


p/i//fAfiy //KisKi/t  p/imr  s/n/fitp  \ 


PftOX/M/IL  CND  OF  /L£Uff 


A  C.  CorrcY 


■jtitjH  m  MmTA/fos/s 


Fig.  475. — 9.  Partial  suture  distal  and  ilei'm.      10.  Meentery  ligated.      11.  Division  of  mesen- 
tery,     12.  Proximal  gut  closed. — {Coffey,  Annals  of  Surgery.) 


VOLVULUS. 


357 


or  an  anastomosis  may  be  established  between  the  open  gut  above  and  below 
the  lesion. 

5.  Under  certain  circumstances,  e.  g.,  prostration,  etc.,  it  may  be  wise  to 
make  an  artificial  anus,  whether  accompanied  by  excision  of  the  intussuscep- 
tion or  n^t.  The  pi-ognosis  must  always  be  bad  when  the  intussusception  is 
left  unreduced,  even  though  the  continuity  of  faecal  circulation  is  provided  for, 
as  gangrene  or  inflammation  of  the  involved  intestine  is  liable  to  occasion  a 
fatal  peritonitis. 

The  vital  importance  of  early  operation  in  intussusception  is  clearly  demon- 
strated by  Clubbe's  statistics.  ("Brit.  Journal  Children's  Diseases,"  July, 
1909.)  During  the  year  1908  there  were  thirty-three  cases  of  intussus- 
ception treated  in  the  Royal  Alexandra  Hospital  for  sick  children  in  Sydney 


Fig.  476. 


with  only  two  deaths.  During  the  same  period  Clubbe  himself  treated  twenty- 
six  cases  without  a  death.  These  remarkable  results  Clubbe  attributes  to  the 
early  diagnoses  made  by  the  physicians  who  first  saw  the  cases.  None  of  the 
patients  were  seen  by  him  later  than  fifty-three  hours  from  the  beginning 
of  the  trouble.  In  his  opinion  laparotomy  constitutes  the  only  treatment. 
Clubbe's  total  experience  constists  of  157  operations  for  intussusception  with 
the  following  striking  results:  Of  the  first  fifty  patients  twenty-five  died,  i.  e., 
50  per  cent.;  of  the  second  fifty  patients  twelve  died,  i.  e.,  25  per  cent.;  of  the 
third  fifty  patients  four  died,  i.  e.,  8  per  cent.;  of  the  last  seven  patients  none 
died,  i.  e.,  o  per  cent. 

Volvulus. — Open  the  abdomen.  Find  the  site  of  obstruction.  Empty 
the  gut  by  incision.  Gently  endeavor  to  unravel  the  knotted  or  twisted  intes- 
tine. If  reduction  is  impossibe  and  there  is  no  interference  with  the  blood- 
supply  of  the  involved  gut,  establish  an  anastomosis  between  the  gut  above 
and  below.  If  the  blood-supply  is  threatened  or  if  for  other  reasons  the  step 
seems  proper,  excise  the  involved  gut.  WTiere  radical  treatment  is  impossible, 
the  operation  of  intestinal  exclusion  or  segregation  may  be  employed. 

A  curious  cause  of  chronic  obstruction  and  the  most  frequent  cause  of 
volvulus  of  the  sigmoid  colon  is  the  so-called  "retractile  meso-sigmoiditis." 


358 


OPERATIONS    ON   THE   INTESTINES. 


Fig.  477. 


From  some  ill-defined  cause  the  base  of  the  meso-sigmoid  becomes  covered 
transversely  by  bands  of  scar  tissue  which  contract  and  in  severe  cases  may 
bring  both  segments  of  the  sigmoid  together  like  the  barrels  of  a  gun.  This  of 
course  can  cause  narrowing  of  the  lumen  and  obstruction  with  subsequent 
dilatation  of  part  of  the  sigmoid  loop  and  of  the  descending  colon.  Distention 
of  the  bowel  and  interference  with  the  circulation  are  liable  to  lead  to  ulcera- 
tion of  the  mucosa,  etc.  Fixation  or  stiffening  of  the  sigmoid  is  a  predisposing 
cause  of  volvulus. 

Treatment. — If  the  bowel  does  not  seem  severely  affected,  divide  the  bands 
of  scar  tissue  which  contract  the  meson;  in  some  cases  this  permits  the  meson 
to  spread  out  to  its  normal  condition.  If  the  above  measure  fails  to  release  the 
meson  or  if  the  gut  is  much  affected  it  is  advised  to  resect  the  involved  intestine. 

In  some  cases  an  anastomosis  might  overcome 
the  trouble.  (Duval,  "Arch,  des-malad.  de 
I'appar.  digestif,"  1*907,  No.  i;  "Ref.  Cen- 
tralblatt  fur  Chir.,"  1907,  No.  37.) 

Bands,  etc. — Bands  or  strands  of  omen- 
tum, etc.,  causing  obstruction  are  to  be  doubly 
ligated  and  divided,  or  rather  excised.  When 
dividing  such  bands,  examine  them  carefully 
lest  they  should  consist  of  diverticula  with 
mucous  lining,  in  which  case  they  must  be 
treated  in  the  same  fashion  as  the  stump  left 
by  the  excision  of  the  vermiform  appendix. 

Sometimes  bands  pressing  on  the  gut  cause  gangrene,  the  gangrene  involv- 
ing all  or  nearly  all  of  the  circumference  of  the  gut  while  it  involves  little  of  the 
long  axis  of  the  gut.  This  segment  of  gut  may  be  excised  though  it  is  prob- 
ably much  better,  especially  in  the  feeble,  to  invaginate  the  gangrenous  gut 
by  a  row  of  Lembert  sutures.  The  invaginated  tissue  is  dead  and  soon  sloughs 
off  leaving  the  lumen  of  the  gut  patent  (Fig.  477).  This  operation  was  devised 
by  J.  E.  Summers  and  carried  out  successfully  by  him  in  three  cases;  two  of 
these  strangulated  hernias  and  one  was  of  gun-shot  wound  of  the  intestines. 
Adhesions. — The  best  treatment  for  obstruction  from  adhesions,  to  use 
an  Irishism,  is  not  to  have  the  adhesions.  The  principal  prophylatic  means 
to  this  end  is,  when  operating,  to  leave  as  few  raw  surfaces  as  possible  within 
the  belly.  WTierever  possible,  raw  surfaces,  pedicles,  etc.,  should  be  covered 
with  peritoneum,  even  if  some  plastic  work  be  required  for  this  purpose. 
Where  it  is  impossible  to  cover  the  surfaces  with  neighboring  peritoneum, 
portions  of  omentum  may  be  ligated  and  cut  off,  and  these  fragments  plastered 
over  the  raw  surface.  Cargile's  ingenious  membrane  is  useful  for  the  same 
purpose  and  is  probably  better  than  the  omental  graft.  The  active  treatment 
of  adhesions  is  to  break  them  up,  either  by  sharp  or  blunt  dissection,  and  cover 
the  raw  surface  as  above  described.  When  a  gut  is  adherent  to  the  parietal 
peritoneum  or  to  an  organ  of  lesser  importance,   and  in  freeing  it  injury  to 


ENTEROSTOMY.  359 

one  or  the  other  is  probable,  be  careful  to  sacrifice  the  less  rather  than  the  more 
important  organ.  If  it  is  impossible  safely  to  separate  the  adhesion  causing 
obstruction  restore  the  faecal  circulation  by  establishing  an  anastomosis  be- 
tween the  gut  above  and  below  the  obstruction. 

Foreign  Bodies. — For  the  treatment  of  obstruction  due  to  this  cause  see 
remarks  on  enterotomy  (page  332). 

Enterostomy. — The  term  "enterostomy"  signifies  an  operation  to  estab- 
lish a  communication  between  any  portion  of  the  intestine  and  the  exterior 
of  the  body,  whether  this  opening  be  used  for  the  introduction  of  food,  etc., 
or  for  the  evacuation  of  intestinal  contents. 

Jejunostomy. — This  operation  is  of  value  in  providing  absolute  rest  to 
the  stomach  in  cases  of  hemorrhage  when  other  more  direct  methods  of  treat- 
ment are  unavailable,  v.  Mikulicz  considers  jejunostomy  "inhuman"  when 
used  to  prolong  life  in  cases  of  stenosis  from  gastric  cancer. 

The  Operation. — Expose  and  examine  the  stomach  exactly  as  in  gastro- 
enterostomy in  order  to  prove  that  some  other  and  better  operation  than  jejun-. 
ostomy  may  not  be  possible.  Bring  a  loop  of  jejunum,  6  or  8  inches  below  the 
duodenojejunal  angle,  into  the  abdominal  wound  and  suture  it  to  the  fascia 
and  skin.  Close  the  excess  of  parietal  wound.  Either  at  the  same  sitting  or  a 
few  days  later  make  an  opening  into  the  exposed  portion  of  jejunum  of  a  size 
suflacient  for  the  introduction  of  a  soft-rubber  catheter.  Feed  with  predigested 
food  through  the  catheter. 

An  imitation  of  the  Stamm-Kader  operation  is  better.  The  great  objec- 
tion to  jejunostomy  is  the  constant  and  inevitable  escape  of  bile  and  pancreatic 
juice  through  the  fistula.  To  obviate  this  evil  Maydl,  after  exposing  the  je- 
junum, divides  it  transversely  about  8  inches  below  its  origin;  the  open  end  of 
the  upper  segment  he  implants  into  the  side  of  the  lower,  about  8  inches  below 
the  line  of  section,  and  then  unites  the  open  end  of  the  lower  segment  to  the 
skin.  The  principle  is  indentical  with  that  of  Roux's  gastro-enterostomy,  and 
is  most  excellent;  the  only  criticism  on  it  is  that  patients  requiring  jejunos- 
tomy are  usually  in  a  very  feeble  condition  and  cannot  withstand  much  opera- 
tive interference. 

Instead  of  a  rather  complicated  Maydl  operation,  one  may  make  an  entero- 
enterostomy  between  the  afferent  and  efferent  segments,  and,  if  desired,  oblit- 
erate the  lumen  of  the  afferent  segment,  by  means  of  a  purse-string  suture, 
between  the  site  of  the  anastomosis  and  the  fistula. 

Colostomy  (often  called  colotomy). — The  most  common  indication  calling 
for  colostomy  is  obstruction,  and  then,  according  to  the  method  of  operating 
adopted,  either  a  part  or  the  whole  of  the  intestinal  contents  escape  through 
the  artificial  anus.  When  operation  is  indicated  for  the  application  of  reme- 
dies (douches,  etc.)  to  the  inside  of  the  colon  some  method  is  adopted  by 
which  escape  of  faeces  is  prevented  (see  caecostomy)  or  appendicostomy  is 
substituted  for  colostomy. 

Lumbar  Colostomy. — The  operation  is  practically  the  same  whether  it  is 


360  OPERATIONS    ON   THE   INTESTINES. 

done  on  the  right  or  the  left  side.  The  following  description  applies  to  the 
left  lumbar  colostomy: 

Step  I. — Place  the  patient  on  his  right  side  with  a  firm  rounded  pillow 
under  his  right  loin.  Find  a  point  on  the  crest  of  the  ilium  midway  between 
its  anterior  and  posterior  superior  spines.  From  a  spot  a  little  in  front  of,  and 
I  inch  above,  the  mid-point  of  the  ilium,  make  an  incision,  3  to  4  inches  in  length 
along  an  imaginary  line  leading  to  the  junction  of  the  spine  and  the  last  rib 
(Bryant's  incision).  Divide  the  skin  and  subjacent  muscles  along  the  whole 
length  of  the  superficial  incision.  Attend  to  hemostasis.  Expose  and  divide 
the  transversalis  fascia,  exposing  the  subperitoneal  fat. 

Step  2. — With  blunt  dissection  penetrate  the  exposed  fat  in  which  the  colon 
is  to  be  found.  The  colon  may  always  be  discovered  in  front  of  the  lower 
border  of  the  kidney.  Be  careful  not  to  open  the  peritoneum;  but  if  this  acci- 
dent occurs,  make  use  of  the  opening  to  aid  in  locating  the  colon;  which  being 
done,  close  the  peritoneum  either  by  suture  or  ligature. 

Step  3. — Method  A. — Having  found  the  colon,  pull  it  up  into  the  wound 
and  pass  a  stout  suture  through  the  skin  (not  the  muscles)  on  one  side  of  the 
wound,  through  the  colon,  and  out  through  the  skin  on  the  other  side.  Clean 
the  lumbar  wound  and  close  its  deep  parts  with  a  few  catgut  sutures.  Close 
the  superficial  lumbar  wound  with  silkworm-gut,  except  opposite  the  prolapsed 
gut.  Make  a  small  opening  into  the  gut  over  the  suture  which  traverses  its 
lumen.  Pick  up  and  pull  out  the  centre  of  the  suture  traversing  the  gut  and 
divide  it.  Tie  the  two  halves  of  the  suture  and  thus  fix  the  sides  of  the  intes- 
tinal opening  to  the  skin.    Introduce  any  more  sutures  which  may  be  necessary. 

Method  B. — Operate  as  above,  but  instead  of  merely  incision  of  the  colon, 
completely  divide  it,  close  its  lower  segment  completely,  and  suture  the  whole 
circumference  of  the  upper  segment  to  the  skin  (Madelung). 

Method  C. — Bring  a  knuckle  of  gut  outside  the  wound,  protect  it  with 
dressings,  and  open  it  after  the  lapse  of  three  or  four  days.  Any  lumbar 
wound  which  is  in  excess  of  what  is  required  for  the  passage  of  the  gut  must 
be  closed  by  sutures.  It  is  unnecessary  to  fix  the  gut  in  the  wound  by  means 
of  sutures. 

Inguinal  Colostomy. — When  the  operation  is  done  on  the  left  side,  it  may 
be  named  sigmoidostomy,  but  the  operation  is  practically  the  same  whether  it 
be  a  right  inguinal  colostomy  or  a  sigmoidostomy.  A  sigmoidostomy  will 
be  here  described. 

Step  I. — Draw  an  imaginary  line  from  the  anterior  superior  spine  to  the  um- 
bilicus; make  an  incision  2  1/2  inches  long,  crossing  this  line  at  right  angles 
and  distant  i  1/2  inches  from  the  anterior  superior  spine.  One-half  the  cut 
is  above  the  line  and  one  half  below  (Harrison  Cripps'  incision). 

Step  2. — Find  the  colon,  recognizable  from  its  longitudinal  muscular  bands 
and  appendices  epiploicse.     Pull  it  into  the  wound. 

Step  3. — Method  A. — Pass  two  silk  sutures,  two  inches  apart,  through  the 
free  margin  of  the  gut.     These  are  for  traction  purposes  and  serve  as  guides. 


COLOSTOMY.  361 

Suture  the  loop  of  gut  to  the  edges  of  the  inguinal  wound.  If  the  case  is  urgent, 
open  the  gut  at  once;  if  there  is  no  urgency,  apply  dressings  and  incise  the  colon 
after  the  lapse  of  three  or  four  days.  In  this  operation  there  is  no  attejnpt  made 
to  compel  the  complete  evacuation  of  the  bowel  through  the  artificial  opening; 
much  of  the  colonic  contents  are  at  liberty  to  pass  down  into  the  lower  gut. 

Method  B. — Gently  pull  out  of  the  wound  as  much  of  the  upper  segment 
of  gut  as  will  come  down  and  push  it  back  again  through  the  lower  angle  of 
the  wound.  This  is  done  so  that  the  intestinal  opening  may  be  made  in  a  part 
of  the  gut  well  supported  by  mesentery,  and  thus  prolapse  be  avoided.  In- 
troduce traction  sutures  as  in  Method  A.  Suture  the  protruded  loop  of  gut  to 
the  abdominal  wound.     The  sutures  should  be  so  placed  that  at  least  two- 

Fosition  q/Farietal 

■7  Wound 


Fig.  478.  Fig.  479. 

thirds  of  the  circumference  of  the  gut  is  external  to  the  line  of  stitches.  Open 
the  gut  either  immediately  or  after  the  lapse  of  3  or  4  days.  The  object  of 
making  so  much  gut  protrude  is  to  form  a  spur  or  obstacle  to  the  passage  of 
faeces  into  the  lower  segment  of  bowel. 

Method  C  is  almost  the  same  as  Method  B.  After  pulling  the  gut  down- 
wards so  as  to  obtain  mesenteric  support,  pass  a  glass  rod  under  the  selected 
loop  of  gut,  through  its  mesentery.  The  ends  of  the  glass  rod  rest  on  each  side 
of  the  skin-wound  and  support  the  loop  of  gut  (Fig.  478).  Close  the  belly- 
wound,  leaving  sufficient  room  for  the  passage  of  the  loop  of  gut  held  in  place 
by  the  glass  rod.  Apply  dressings.  Remove  the  glass  rod  and  open  the  gut 
after  union  has  taken  place  between  the  gut  and  the  parietes.  This  is  a  conve- 
nient and  good  method. 

Method  D.- — Find  the  colon,  pull  it  downwards  so  as  to  provide  mesenteric 
support.  Apply  clamps  to  the  gut  and  divide  it.  Close  the  lumen  of  the  lower 
segment  by  inverting  its  cut  edges  and  suturing.  Suture  the  whole  circum- 
ference of  the  upper  segment  to  the  skin.  Close  the  excess  of  skin- wound 
after  removing  the  clamps. 

Method,  E  and  F. — Instead  of  dividing  the  gut,  and  before  opening  it, 
Mosetig-Moorhof  creates  a  valvular  obstruction  in  the  lower  segment  by  in- 
serting a  few  Lembert  sutures  (Fig.  479).  The  same  object  may  be  attained 
by  encircling  the  gut  A\ith  a  loop  of  wire  or  with  a  purse-string  suture  of  silk. 


362 


OPERATIONS    ON   THE   INTESTINES. 


Method  G  (Wyeth's  Operation). — In  the  author's  opinion  this  is  the  method 
of  choice.  All  the  methods  already  described  have  been  devised  in  the  belief 
that  prolapse  of  the  afferent  segment  of  the  gut  is  the  principal  trouble  after 
colostomy.  This  belief  is  not  correct.  The  chief  trouble  is  that  there  is  no 
rectum  to  act  as  a  natural  reservoir  for  faeces.  The  following  operation 
provides  such  a  reservoir  and  also  prevents  any  great  prolapse  of  mucous 
membrane. 

Step  I. — Make  an  incision  through  the  skin  alone,  parallel  to  and  i  1/4 
inches  below  the  Harrison  Cripps'  line  of  incision  (page  360).  Pull  the  supe- 
rior edges  of  the  skin  incision  upwards  so  as  to  expose  the  deep  structures  of 

the  belly-wall  at  the  Harrison  Cripps'  line  (Fig. 
480).  Divide  the  deep  structures  along  this  line 
and  so  open  the  belly. 

Step  2. — Pull  the  sigmoid  flexure  out  of  the 
wound ;  push  all  excess  of  sigmoid  up  into  the 
Ijelly  so  that  as  little  gut  is  left  below  the  eviscer- 
ated loop  as  possible,  i.  e.,  the  portion  of  gut  to 
be  united  to  the  belly-wall  is  chosen  as  low  down 
the  intestine  as  is  possible.  By  this  means  a 
faecal  reservoir  is  provided. 

Step  3. — Treat  the  eviscerated  segment  of  gut 
in  much  the  same  manner  as  is  recommended  in 
the  preceding  methods.  If  it  is  desired  to  open 
the  gut  at  once,  it  is  wise  to  fasten  a  tube  into  it  by  means  of  a  purse-string 
suture,  much  in  the  manner  described  in  Paul's  colectomy.  Some  surgeons 
strongly  advise  against  suturing  the  parietal  peritoneum  to  the  skin,  as  when  this 
is  done  there  is  not  such  good  union  between  the  gut  and  the  parietes.  Excise 
all  the  appendices  epiploicae  from  the  eviscerated  segment  of  gut,  as  otherwise 
they  will  surely  slough  off,  slowly  and  with  much  stench.  In  applying  dress- 
ings always  separate  the  dressings  from  the  exposed  gut  by  a  layer  of  rubber 
tissue  or  perforated  oiled  silk.  This  simple  device  saves  much  trouble  from 
the  sticking  of  dressings  to  the  parts  and  is  very  conducive  to  cleanliness  and 
avoidance  of  stench.  In  time  the  opening  in  the  skin  and  that  through  the 
deeper  structures  come  to  lie  close  to  each  other;  not  so  close,  however,  as  to 
do  away  with  the  valve  action  desired. 

Instead  of  passing  a  glass  rod  through  the  mesentery  of  the  eviscerated 
gut  to  hold  the  gut  in  place,  a  good  plan  is  to  effect  the  same  purpose  with  a 
flap  of  skin  (Mixter.)  The  method  of  carrying  this  out  is  suflSciently  shown  in 
Fig.  481. 

Method  H. — Ccecostomy. — The  author  has  found  this  operation  of  value 
as  a  substitute  for  appendicostomy. 

Step  I. — Expose  the  caecum  by  means  of  the  McArthur-McB urn ey  muscle- 
splitting  method. 

Step  2. — Choose  a  part  of  the  caecum  which  can  be  easily  approximated  to 


Fig.  480. 


C^COSTOMY. 


36: 


the  abdominal  wound  and  introduce  a  purse-string  suture  of  catgut  (Fig.  482) 
penetrating  the  whole  thickness  of  the  csecal  wall. 

Step  3. — Incise  the  gut  inside  the  circle  formed  by  the  purse-string  suture. 
Through  this  incision  pass  the  bulb  of  a  Jacob's  self-retaining  catheter  into 
the  lumen  of  the  gut.  Tie  the  purse-string  snugly  around  the  shaft  of  the 
catheter  but  not  tighdy  enough  to  obstruct  its  lumen.  No  faecal  matter  can  now 
escape  alongside  the  catheter  and  no  bleeding  from  the  intestinal  wound  is 
possible.     Cleanse  the  field  of  operation. 

Step  4. — At  a  distance  of  1/4  to  1/2  inch  from  the  catheter  introduce  a 
purse-string  suture  of  hemp  or  silk  and  tie  this  line  of  suture  snugly  (but  not 
too  tightly)  around  the  shaft  of  the  catheter.  Leave  the  ends  of  the  suture 
long. 


P^IG.    481. 


Fig.  482. 


Step  5. — Pull  the  free  end  of  the  catheter  through  the  abdominal  wound  so 
as  to  bring  the  caecum  into  apposition  with  the  parietal  peritoneum.  Stitch 
the  long  ends  of  the  purse-string  suture  to  the  parietal  peritoneum.  Close 
the  abdominal  wound.  Before  applying  dressings  pull  the  catheter  in  such  a 
fashion  that  its  bulb  (inside  the  caecum)  will  bring  the  caecum  into  contact, 
with  the  parietal  peritoneum.  Before  closing  the  abdominal  wound,  the  caecum, 
near  the  catheter,  may  if  desired  be  united  to  the  parietal  peritoneum  by  one 
or  two  stitches.  This  is  rarely  necessary.  Before  introducing  the  catheter 
into  the  caecum  its  free  end  may  be  clamped  by  a  hemostat. 

The  catheter  is  left  in  situ  as  long  as  it  is  required  for  irrigation  of  the  colon. 
To  remove  the  catheter  cut  it  flush  with  the  skin  and  with  a  probe  passed  through 
the  lumen  of  the  remnant  poke  the  bulb  into  the  gut.  Owing  to  the  invagina- 
tion of  the  c^cal  wall  the  fistula  closes  promptly  as  soon  as  the  catheter  is 
removed. 

Weir  suggested  that  the  appendix  might  be  used  in  the  formation  of  a  fistula 
through  which  the  colon  could  be  irrigated.     The  operation  is  only  feasible 


364  OPERATIONS    ON   THE   INTESTINES. 

when  the  appendix  has  a  lumen  large  enough  to  permit  the  passage  of  a  small 
catheter  and  when  absence  of  adhesions  and  presence  of  sufficiently  long 
meso-appendix  permit  its  being  brought  out  through  the  abdominal  wall  with- 
out interference  with  its  nutrition. 

Step  I. — Open  the  abdomen  through  a  small  incision  as  for  appendectomy. 

Step  2. — Bring  the  appendix  out  through  the  wound  without  twisting  or 
exerting  undue  pressure  on  its  meson. 

Step  3. — Prevent  retraction  of  the  appendix  into  the  abdomen  either  by 
uniting  the  caecum  or  the  appendix  to  the  parietes  by  one  or  more  sutures, 
or  by  passing  a  safety  pin  through  the  meso-appendix  exactly  as  a  rubber 
drainage-tube  is  secured. 

Step  4.-^Close  the  abdominal  wound  being  careful  not  to  exert  pressure  on 
the  appendix  or  its  blood-supply.  After  adhesions  have  formed  between  the 
appendix  and  the  wound  cut  off  the  protruding  tip  of  the  appendix  flush  with 
the  skin  and  introduce  a  soft-rubber  catheter  into  the  caecum  as  often  as  may  be 
required.  When  it  is  desired  to  close  the  fistula  remove  the  mucosa  of  the 
appendix  either  by  the  cautery  or  by  dissection  or  remove  the  appendix  itself. 

ANTERIOR  COLOSTOMY.     (MIXTER'S  OPERATION.) 

Step  I. — Make  the  incision  shown  in  Fig.  483.  The  outer  portion  of  the 
incision  must  be  a  short  distance  inside  of  the  outer  edge  of  the  rectus  muscle. 
The  incision  divides  the  skin,  subcutaneous  tissue  and  the  rectus  fascia.  Reflect 
outwards  the  quadrilateral  flap  outlined. 

Step  2. — Split  the  rectus  muscle  near  its  outer  margin.     Open  the  abdomen. 

Step.  3. — Deliver  a  loop  of  the  sigmoid  as  in  Step  2,  Method  G. 

Step  4. — Split  the  meso-sigmoid  for  about  2  inches  at  a  right  angle  to  the 
long  axis  of  the  bowel.  Suture  the  two  edges  of  the  middle  portion  of  the 
separated  rectus  muscle  together  through  the  opening  in  the  meso-sigmoid 
(Fig.  484). 

Step  5.— Push  the  reflected  flap  of  skin  and  rectus  fascia  through  the  opening 
in  the  meso-sigmoid  and  suture  it  in  its  original  position,  (Fig.  485). 

After  four  or  five  days  the  exposed  coil  of  sigmoid  may  be  resected,  when 
bleeding  from  the  cut  ends  of  the  intestine  may  be  controlled  by  a  continuous 
suture  of  catgut.  The  proximal  and  distal  openings  are  wide  apart  and  the 
rectus  acts  as  a  sphincter.  Through  the  distal  opening  it  is  easy  to  flush  the 
rectum  (Fig.  486).  If  obstruction  is  acute  one  may  open  the  bowel  in  Step 
5  and  insert  a  glass  tube  (Paul's  tube;  Mixter's  tube). 

Closure  of  Artificial  Anus  or  of  Faecal  Fistulas. — When  colostomy  has 
been  performed  as  a  preliminary  step  in  excision  of  the  rectum  or  for  therapeutic 
purposes,  or  when  the  obstruction  which  called  for  it  has  been  removed,  it 
becomes  necessary  to  close  the  artificial  anus.  When  no  "spur"  preventing 
the  onward  passage  of  faeces  is  present,  all  that  may  be  required  is  to  dissect 
the  mucous  membrane  free  from  the  skin,  turn  inwards,  stitch  its  edges  together, 


COLOSTOMY. 


365 


and  then  suture  the  now  raw  edges  of  the  abdominal  wound.  When  a  "spur" 
is  present  (vide  Methods  B  and  C,  page  361),  one  may  apply  a  clamp  to  the  spur 
and  leave  it  in  position  until  by  pressure  it  causes  the  "spur"  to  slough  away 
(Fig.  487).  This  takes  away  all  opposition  to  the  onward  flow  of  the  contents, 
and  fistula  may  be  closed  in  the  manner  already  described.       Such  was  the 


Fig.  483. — ^Mixter's  Anterior  Colostomy. — (Uould.) 
Line  of   incision. 


manner  of  operating  devi'Sed  by  Dupuytren,  and  until  comparatively  recently 
was  the  accepted  method.  The  dangers  of  the  method  are:  (a)  peritonitis; 
(b)  accidental  inclusion  of  a  kunckle  of  intestine  within  the  clamps.  Other 
and  more  precise  methods  are  now  in  use. 

The  Operation. — Prepare  the  patient  by  evacuating  the  bowels  thoroughly 


366 


OPERATIONS    ON    THE    INTESTINES. 


forty-eight  hours  before  operation.     Immediately  prior  to  the  operation  give 
an  opiate  to  keep  the  bowels  inactive  for  a  short  time. 

Step  I. — Cleanse  the  skin  around  the  fistula  and  scrub  the  fistula  itself. 
Cauterize  the  fistulous  opening  with  the  thermocautery,  liquid  carbolic  acid,  or 
pure  formalin.     Close  the  opening  tightly   with   a  purse-string   suture   after 


Fig.  4S4. — Anterior  Culostomy. — {Gould.) 

Sigmoid  withdrawn,  mesentery  pulled  taut  and  incised.     Rectus  muscle  sewed  together 

between  afferent  and  efferent  coils. 


packing  it  with  a  small  plug  of  gauze.  The  suture  is  inserted  in  the  skin,  and 
when  tied  prevents  soiling  of  the  neighborhood  by  intestinal  contents  (Fig, 
488,  L).     Once  more  cleanse  the  field  of  operation. 

Step  2. — Make  an  incision  through  the  parietes  at  a  point  above,  below,  or 


CLOSURE    OF    FISTULA. 


367 


to  the  side  of  the  fistula,  and  open  the  abdominal  cavity.  In  choosing  where 
to  make  this  incision  endeavor  to  find  a  spot  close  to  the  fistula  where  the  tissues 
are  not  much  altered,  and  where  the  viscera  are  not  adherent  to  the  parietal 
peritoneum. 

Step  3. — Introduce  the  finger  into  the   belly  and   explore  the  relations  of 


Fig    485. — Anterior  Colostomy. — {Gould.) 
Flap  fastened  into  original  position  under  arch  of  sigmoid,  with  two  layers  of  sutuies. 

Mixter  tube  in  place. 

the  adherent  gut  to  the  abdominal  w^all.  Guided  by  the  exploring  finger, 
enlarge  the  incision,  making  it  run  around  one  side  of  the  fistulous  opening 
(Fig.  488, 1,  N). 

Step  4 — Retract  the  flap  formed  by  the  incision  I,  N.  This  exposes  the 
gut  and  its  connection  with  the  inner  surface  of  the  parietes  at  the  fistula  (Fig. 
489,  X,  Y). 


368 


OPERATIONS    ON   THE   INTESTINES. 


Step  5. — Me'.hod  A. — If  the  connection  between  the  gut  and  the  parietes 
is  small  in  extent,  empty  the  gut  of  its  contents  by  stripping  it  with  the  fingers, 
and  keep  it  empty  by  suitable  clamps.  Protect  the  abdomen  with  pads; 
divide  the  union  between  the  gut  and  the  parietes;  close  the  hole  in  the  gut 
by  a  double  row  of  sutures,  as  is  done  in  enterotomy. 


Fig.  486. — Anterior  Colostomy. — [Gould.) 
Sigmoid  resected  1/4  to  1/2  inch  above  skin  level.     Circumference  of  cut  edges  sewed 

with  catgut. 


Method  B. — If  the  connection  between  the  gut  and  the  parietes  when 
separated  leaves  such  a  defect  that  simple  closure  would  lead  to  stenosis, 
either  counteract  the  effect  of  the  stenosis  by  anastomosing  the  afferent  and 
efferent  loops  or  excise  the  injured  portion  of  gut  and  restore  the  continuity 
of  the  gut  as  is  done  after  any  enterectomy. 


CLOSURE   F^CAL   FISTULA. 


369 


Method  C. — If  the  union  between  the  gut  and  the  parietes  is  very  extensive, 
and  if  for  any  reason  the  above  methods  are  inapplicable, — e.  g.,  presence  of 
extensive  and  dense  adhesions,  or  the  inaccessible  location  of  the  fistula, — then 
the  operation  of  bilateral  exclusion  may  be  performed.  In  this  case  the  next 
step  in  the  operation,  after  the  exclusion  has  been  accomplished,  would  be 
closure  of  the  abdominal  wound  and  removal  of  the  purse-string  suture  around 
the  fistula,  as  that  opening  is  required  for  the  drainage  of  the  excluded  segment 
of  gut.  A  cure  of  the  fistula  may  be  expected,  but  only  after  the  lapse  of 
much  time.  The  method  by  "exclusion"  or  "segregation"  is  not  a  method 
of  choice,  but  of  necessity,  and  when  done,  removal  of  the  mucous  membrane 
from  the  segregated  gut,  if  possible,  is  an  advantage. 

Step  6. — The  continuity  of  the  gut  having  been  estabHshed,  excise  the 
fistula  and  as  much  of  the  surrounding  sclerosed  tissue  as  may  be  necessary 


w 


^' 


Fig.  487. — {Es march 
and  Kowalzig.) 


Fig.  488. 


Fig.  489. 


As  a  rule,  in  severe  cases,  the  whole 
^88,  will  require  removal,  and  some- 


to  secure  healthy  structures  for  suturing. 
of  the  flap  outli  ed  by  the  cut  I,  N,  Fig.' 
times  even  more  tissue  must  be  sacrificed. 

Step  7. — Close  the  abdominal  wound,  preferably  without  drainage. 

The  operation  thus  described  will  generally  be  found  satisfactory.  Its 
extent  is  rendered  necessary  from  the  fact  that  the  fistula  is  usually  surrounded 
by  much  scar  tissue  which,  unless  thoroughly  extirpated,  will  almost  surely 
lead  to  the  formation  of  a  post-operative  hernia.  In  a  few  cases  where  there 
is  not  much  deposit  of  scar  tissue  and  where  the  fistulous  track  is  short  and 
leads  directly  into  the  gut,  a  much  simpler  procedure  may  be  adopted. 

Step  I. — After  thorough  cleansing  of  the  fistula  and  the  whole  neighboring 
skin  make  an  incision  around  the  fistula  at  the  junction  of  the  skin  and  mucous 
membrane.  Through  this  incision  dissect  the  fistulous  track  free  from  its 
surroundings  until  the  gut  is  reached. 

Step  2. — The  fistulous  track  is  now  attached  to  the  gut  alone,  and  hangs 
24 


370  OPERATIONS    ON    THE   INTESTINES. 

on  it  very  much  as  the  vermiform  appendix  hangs  on  the  caecum  after  the 
appendicular  mesentery  is  divided.  Remove  the  fistulous  track  in  the  manner 
as  the  appendix  is  excised  and  treat  the  resulting  stump  similarly. 

Step  3. — Close  the  abdominal  wound  with  or  without  drainage. 

Instead  of  operating  as  above,  one  may  open  the  belly  in  the  middle  line, 
find  the  loops  of  gut  leading  to  and  from  the  artificial  anus,  and  make  an 
anastomosis  between  them,  subsequently  closing  the  fistula.  In  this  method 
it  is  much  easier  to  keep  the  peritoneum  from  being  soiled  than  in  the  preceding. 

When  it  becomes  desirable  to  close  the  artificial  anus  made  by  dividing 
completely  the  gut,  closing  and  dropping  its  lower  segment  into  the  belly, 
and  suturing  the  upper  segment  to  the  abdominal  wound,  the  operation  to  be 
chosen  is  one  done  on  the  following  lines: 

Empty  the  bowels  by  means  of  purgatives  or  enemata.  Administer  an 
opiate  shortly  before  operating  to  lock  up  the  bowels.  Pack  the  artificial 
anus  with  gauze  to  prevent  escape  of  contents  during  the  operation.  Open 
the  belly,  preferably  in  the  middle  line.  Find  the  lower  segment  of  gut. 
Find  the  loop  of  gut  which  is  attached  to  the  skin  and  forms  the  artificial  anus. 
Make  an  anastomosis  between  the  lower  segment  of  gut  and  loop  of  gut  above 
that  which  forms  the  artificial  anus.  Close  or  excise  the  artificial  anus  either 
at  the  same  sitting  or  subsequently.     Close  the  abdominal  wound. 


CHAPTER  XXXIII. 
THE  VERMIFORM  APPENDIX  AND  PERITONEUM. 

OPERATIVE  TREATMENT  OF  APPENDICITIS. 

Appendicectomy. — As  different  methods  have  been  devised  for  carrying 
out  almost  every  step  of  appendicectomy,  it  may  be  convenient  to  describe 
shortly  a  number  of  these  methods  under  the  headings  Step  i,  2,  etc. 

Step  I. — Opening  the  Abdomen. — (A)  McBurney  Metliod.^ — This  method 
is  especially  suitable  where  no  drainage  of  the  abdominal  cavity  is  required; 
drainage,  however,  may  be  effected  either  through  the  wound  itself  or  better, 
through  a  special  stab  wound  made  in  a  convenient  position.  Under  proper 
conditions  the  method  is  ideal.  The  principle  involved  is  avoidance  of 
transverse  division  of  muscles  or  tendinous  fibres,  so  that  when  healing  has 
taken  place  there  is  no  post-operative  weakness  of  the  belly-wall. 

The  Operation. — Make  a  three  inch  incision  through  the  skin  and  subcu- 
taneous fat.  The  cut  begins  at  a  point  one  inch  above  a  line  joining  the  anterior 
superior  spine  of  the  ilium  and  the  umbilicus,  and  crosses  it  at  a  point  one  and 
one-half  inches  from  the  anterior  superior  spine.  The  incision  runs  downwards 
and  inwards  in  the  same  direction  as  the  fibres  of  the  external  oblique  muscle 
and  aponeurosis.  Separate  the  fibres  of  the  external  oblique  for  the  whole 
length  of  the  wound  without  cutting  any  of  them  transversely.  This  can 
be  done  with  the  handle  of  a  knife  and  the  finger.  With  retractors  pull  apart 
the  edges  of  the  wound  in  the  external  oblique  and  expose  the  underlying 
internal  oblique  and  transversalis  muscles,  whose  fibres  run  approximately 
at  right  angles  to  the  superficial  wound.  With  blunt  dissection  traverse 
these  muscles  so  as  to  make  a  wound  in  them,  parallel  to  their  fibres  and  at 
the  right  angles  to  wound  in  the  external  oblique.  Blunt  retractors  are  intro- 
duced to  keep  this  wound  open  and  expose  the  fascia  transversalis,  which  is 
divided  in  the  same  direction  as  the  wound  of  the  internal  oblique.  After 
this  the  peritoneum  is  picked  up  in  forceps  and  opened.  Special  care  has  to 
be  taken  in  opening  the  peritoneum,  as  it  is  frequently  found  adherent  to  the 
caecum  or  other  abdominal  contents.  The  same  rules  apply  to  the  opening 
of  the  peritoneum  as  to  the  opening  of  the  sac  in  cases  of  hernia. 

Closure  of  the  Wound. — Separate  suture  of  the  peritoneum  and  of  the 
transversalis  fascia.  The  wound  in  the  internal  oblique  and  transversalis 
muscles  requires  but  one  or  two  points  of  suture.     Suture  of  the  external 

*L.  L.  McArthur  undoubtedly  devised  and  carried  out  this  muscle  splitting  operation 
in  about  thirty  cases  before  McBurney  did  so.  Unfortunately  he  failed  to  publish  his 
method.  Needless  to  say  McBurney  was  not  acquainted  with  the  above  fact  when  he  de- 
scribed his  operation. 


372 


VERMIFORM  APPENDIX  AND    PERITONEUM. 


oblique.     Suture  of  tl^e'skin.     Suture  material  varies  according  to   the  fancy 
of  the  operator.     The'  author  prefers  catgut. 

If  the  appendix  is  long  and  extends  far  up  towards  the  liver  its  distal  end 
may  be  exposed  through  a  second  incision  entirely  similar  to  the  first  but  at  a 
higher  level.  Working  through  both  incisions  a  difficult  operation  may  be 
much  facilitated  and   no   greater  danger  of  post-operative  hernia  incurred. 


Fig.  4QO. 
X.  Ant.  Sup.  Spine.     A.  E.xt.  Edge  Rectus.     B.  Umbilicus.     C.  Fascia  of  External  oblique. 

D.  E.xposed  Rectus. 

In  order  to  obtain  more  room  Weir,  after  splitting  the  fascia  of  the  external 
oblique,  separates  it  from  the  anterior  surface  of  the  rectus,  splits  the  internal 
oblique  and  transversalis  like  McBurney,  but  continues  the  split  or  incision 
transversely  through  the  anterior  layer  of  the  sheath  of  the  rectus,  retracts  the 
rectus  itself  towards  the  middle  line,  and  lastly  divides  the  posterior  layer 
of  the  rectus  sheath  along  with  the  peritoneum.     Closure  of  this  wound  presents 


INCISIONS.  373 

no  special  difficulties.     Note  that  in  dividing  the  posterior  layer  of  rectus  sheath 
the  epigastric  vessels  ought  to  be  found  and  ligated  before  division. 

(B)  G.  G.  Davis  Incision  ("Annals  of  Surg.,"  Jan.,  1906). — Locate  the 
the  outer  border  of  the  right  rectus  at  the  level  of  the  anterior  superior  spine. 
Make  a  transverse  incision  through  the  skin  i  1/2  inches  long,  having  the  edge 
of  the  rectus  as  its  mid-point  (Fig.  490).  Divide  the  aponeurosis  of  the  external 
oblique  obliquely  to  the  direction  of  its  fibres,  but  directly  in  the  line  of  the  skin 
wound.  Split,  do  not  cut,  the  internal  oblique  and  transversalis  muscles. 
Open  the  peritoneum.  Carry  the  cut  inwards  through  the  anterior  layer  of 
the  sheath  of  the  rectus.  Retract  the  rectus  towards  the  middle  line.  Divide 
the  posterior  layer  of  rectus  sheath  along  with  the  peritoneum. 

If  more  room  is  required,  prolong  the  incision  outward  towards  or  even  to 
the  anterior  superior  spine  and  if  requisite  inwards  through  the  rectus  sheath 
to  within  an  inch  of  the  median  line. 

(C)  Rectus  Incision. — Locate  the  outer  border  of  the  right  rectus.  Begin- 
ning at  a  point  one  inch  above  a  line  joining  the  anterior  superior  spine  to  the 
umbilicus,  make  an  incision  downwards,  about  one-half  inch  internal  and 
parallel  to  the  edge  of  the  rectus.  The  incision,  21/2  inches  in  length,  may 
be  increased  if  necessary.  Expose  and  split  the  anterior  layer  of  rectus  sheath. 
Split  the  rectus  muscle  or  retract  the  muscle  (Kammerer;  Lennander;  Battle; 
Jaboulay)  inwards  to  expose  the  posterior  layer  of  sheath.  Divide  the  pos- 
terior layer  of  rectus  sheath  and  open  the  abdomen.  This  incision  is  good  in 
almost  all  cases  of  appendicitis  except  when  there  is  a  large  abscess  present 
and  located  more  or  less  externally.  The  wound  may  be  closed  in  layers  or 
by  through-and-through  sutures. 

(D)  Incision  through  the  linea  semilunaris  requires  no  special  description. 

(E)  Oblique  Incision. — Locate  the  outer  border  of  the  right  rectus  muscle 
Beginning  at  a  point  one  inch  above  an  imaginary  line  joining  the  anterior 
superior  iliac  spine  to  the  umbilicus,  make  an  incision  parallel  to,  and  about 
3/4  of  an  inch  external  to,  the  edge  of  the  right  rectus  muscle.  This  cut  runs 
downwards  and  slightly  inwards  for  about  3  inches.  The  fibres  of  the  exter- 
nal oblique  and  its  aponeurosis  can  be  split  longitudinally  by  blunt  dissection; 
the  deeper  structures  are  divided  in  the  direction  of  the  wound.  The  usual 
care  must  be  exercised  in  opening  the  peritoneum.  A  good  practical  rule  to 
adopt  in  operating  is  as  follows:  Make  a  3-inch  incision  as  above  described 
down  to  the  external  oblique;  make  a  small  opening  through  the  remainder 
of  the  belly-wall;  introduce  the  forefinger  to  explore;  if  it  is  easy  to  complete 
the  removal  of  the  appendix  through  the  small  opening,  do  so;  if  not,  enlarge 
the  wound  to  the  necessary  extent.  The  size  of  the  skin-wound  is  of  little 
importance — the  smaller  the  wound  of  the  deep  structures  (of  the  essential 
belly-wall),  the  less  danger  will  there  be  of  hernia.  The  wound  must  be 
large  enough  to  permit  of  easy  access  to  the  field  of  work.  After  completing 
the  appendicectomy,  the  wound  may  be  closed  in  layers  or  by  one  layer  of 
sutures  traversing  the  whole  thickness  of  the  belly-wall. 


!74 


VERMIFORM   APPENDIX   AND    PERITONEUM. 


(F)  Inferior  or  External  Incision. — From  a  point  about  two  finger  breadths 
internal  to  the  right  anterior  superior  iliac  spine  and  one  inch  above  the  line 
joining  the  umbilicus  and  the  iliac  spinous  process  make  a  3-inch  incision 
crossing  the  above  line  at  right  angles.  Having  made  the  skin-incision,  follow 
the  rules  laid  down  for  Method  C. 

(G)  Through  one  of  the  previous  incisions  an  abscess  has  been  found  but 
not  opened.  This  abscess  lies  posteriorly  and  ought  to  be  evacuated  through 
the  loin,  i.  e.,  extraperitoneally.  Guided  by  the  finger  in  the  belly  make  an 
incision  directly  over  or  better  to  the  outer  side  of  the  abscess.  After  incising 
the  parietes,  but  before  opening  into  the  abscess,  close  the  exploratory  wound, 

penetrate  the  abscess  cavity,  cleanse  and 
drain  it.  In  the  same  manner  when  large 
abscesses  have  been  opened  through  the 
primary  incision,  one  or  more  counter  open- 
ings may  be  made  to  secure  efficient  drainage. 
(H)  In  exceptional  cases  the  primary  open- 
ing may  be  made  wherever  the  abscess  tumor 
indicates,  e.  g.,  the  writer  has  opened  an  ap- 
pendicial  abscess  in  the  left  iliac  region. 

Step  2. — Search  for   and   isolation   of    the 
appendix. 

(a)  Digital  exploration.  The  forefinger  or, 
if  necessary,  two  fingers  are  introduced  into 
the  belly  and  the  ascending  colon  is  recognized. 
The  finger  follows  the  colon  to  the  end  of  the 
caecum  and  is  systematically  moved  about  its 
blind  extremity,  separating  gently  any  adhe- 
sions which  may  be  present  and  which 
If  the  adhesions  are  firm  or  resist  the  gentle 
the  next  method  to  be  described  must  be  em- 
ployed. The  appendix  may  lie  in  any  position  near  the  end  of  the  caecum 
and  may  be  either  curled  up  on  itself  or  extended.  Having  found  the  appendix, 
gently  separate  it  from  its  surroundings  and  deliver  it  through  the  wound. 
The  mesentery  of  the  appendix  is  transfixed  close  to  the  appendix  and  colon,  a 
ligature  drawn  through,  the  mesentery  ligated  and  divided  (Fig.  491).  If 
the  mesentery  is  voluminous,  it  may  be  necessary  to  apply  two  interlocked  liga- 
tures. The  digital  exploration  may  be  accomplished  as  follows:  Pass  the 
finger  along  the  outer  surface  of  the  colon  over  the  brim  of  the  pelvis  into  the 
true  pelvis.  Feel  for  the  pulsating  iliac  artery.  Slip  the  finger  upwards  on 
the  surface  of  the  artery  and  bring  the  finger  out  of  the  true  pelvis.  If  the 
finger  is  slightly  hooked  while  being  brought  out  of  the  pelvis  it  will  bring  up  a 
loop  of  small  intestine.  This  loop  of  small  intestine  is  the  ileum  close  to  the 
caecum  and  is  within  an  inch  of  the  base  of  the  vermiform  appendix.  The 
treatment  of  the  appendix  itself  belongs  to  Step  3. 


Fig.  4gi. 

interfere   with   the   search, 
manipulations  advised,   then 


APPENDICECTOMY.  375 

(b)  If  it  proves  difl&cult  to  find  and  isolate  the  appendix  by  Method  a, 
the  wound  must  be  enlarged  so  that  the  eye  may  aid  in  the  exploration.  First 
recognize  the  ascending  colon.  This  is  easily  done  by  noting  its  longitudinal 
muscular  bands.  Follow  the  anterior  muscular  band  downwards;  it  leads 
directly  to  the  base  of  the  appendix.*  The  isolation  of  the  appendix  may 
be  accompUshed  in  tw.o  ways:  If  one  readily  finds  its  distal  end,  one  begins 
isolating  there  and  works  towards  the  base.  Any  rigid  adhesions  should  be 
ligated  with  fine  silk  or  catgut  and  divided.  If  adhesions  to  intestines  are 
firm  and  short,  one  must  remember  a  cardinal  rule  in  abdominal  surgerj^, 
viz.,  sacrifice  part  of  what  is  being  removed  if  non-malignant,  rather  than 
injure  the  viscus.  If  necessar}-,  a  thin  layer  of  the  appendicular  wall  (never 
containing  mucosa)  may  be  left  attached  to  a  gut  so  as  to  avoid  laceration  of 
the  gut-wall.  If  it  is  difficult  to  find  the  distal  extremity  of  the  appendix, 
isolation  may  be  begun  at  its  base.  It  is  occasionally  necessary  to  divide  the 
appendix  at  its  base  before  it  can  be  removed.  If  this  is  necessar\',  one  applies 
a  clamp  to  or  ties  a  ligature  around  the  organ  distal  to  the  point  of  section 
and  cauterizes  the  cut  surface.  This  prevents  contamination  by  the  appen- 
dix while  being  isolated  and  while  its  caecal  extremity  or  stump  is  being 
treated.  Under  such  circumstances  Step  3 
is  proceeded  with  before  the  appendix  itself 
is  removed. 

Step  3.— Treatment  of  the  stump.  ..^^^- /«&^ump1/ App/ndZ. 

Method  A . — Tie  a  ligature  tightly  around 
the  appendix  close  to  the  caecum.  Before 
ligating  it  is  best  to  crush  the  base  of  the 
appendix  with  a  strong  clamp  and  then  to 
place  the  ligature  in  the  groove  left  by  the 

clamp.  Cut  away  the  appendix  about  one-fourth  of  an  inch  beyond  the  ligature. 
Thoroughly  cauterize  the  lumen  of  the  stump  with  liquid  carbolic  acid.  Wipe 
away  the  carbolic  acid.  This  method  is  simple  and  gives  excellent  results. 
The  main  objection  to  the  above  is  that  the  ligature  may  possibly  be  applied 
beyond  a  stricture  of  the  appendix,  and  so  there  may  be  recurrence  of  the 
disease  in  the  stump. 

Method  B  avoids  the  disadvantage  pertaining  to  the  preceding  method 
(McBurney).  The  appendix  is  divided  one-fourth  inch  from  the  colon,  the 
edges  of  the  stump  are  seized  with  forceps,  a  probe  is  passed  through  its  lumen 
into  the  colon,  its  mucous  membrane  is  destroyed  by  the  application  either  of 
liquid  carbolic  acid  or  the  fine  point  of  a  cautery.     The  carbolic  acid  may  be 

*  Kolliker  remarks  that  if  the  appendix  is  much  adherent  it  drags  upon  the  longitudinal 
band  and  as  a  consequence  if  the  appendix  is  retrocaecai  the  drag  makes  the  band  curve 
with  its  convexity  towards  the  middle  Hne;  if  the  appendix  is  median  or  if  it  lies  in  the 
pelvis  the  band  is  curved  with  its  convexity  external.  Occasionally  anatomic  anomalies 
puzzle  the  operator.  They  must  be  borne  in  mind.  When  the  cscum  cannot  be  found  in 
the  right  iliac  fossa,  pick  up  the  omentum  and  use  it  as  a  guide  to  the  transverse  colon; 
this  little  "dodge"  has  been  useful  to  the  author.  Transposition  of  viscera  is  a  condition 
which  must  be  remembered. 


376 


VERMIFORM  APPENDIX  AND   PERITONEUM. 


applied  by  means  of  a  grooved  director  or  by  a  little  cotton  tightly  wound  on  a 
fine  probe.  Only  after  the  mucous  membrane  is  destroyed  does  one  apply  a 
ligature  around  the  stump  close  to  the  colon.  This  is  a  thoroughly  reliable 
and  simple  method.  To  eliminate  the  raw  surfaces  left  by  this  method  George 
Gray  sutures  the  stump  of  the  mesoappendix  to  that  of  the  appendix  itself 
(Fig.  492)- 

Method  C. — At  a  point  about  one-fourth  of  an  inch  from  the  colon  a  cir- 
cular incision  is  made  through  the  serous  coat  of  the  appendix,  leaving  the 
muscular  and  mucous  coats  intact.  The  serous  coat  is  separated  from  the 
muscular  up  to  the  colon.  Close  to  the  colon  a  ligature  is  tied  around  the 
tube,  composed  of  muscularis  and  mucosa,  and  the  appendix  removed.  The 
serous  cuff  is  brought  forwards  over  the  stump  and  there  sutured  (Figs.  493, 
494,  495).     The  method  is  safe,  but  cumbrous  and  unnecessary. 


Fig.  493. 


Fig.  494. 


Fig.  495. 


Method  D. — Cut  away  the  appendix  flush  with  the  colon  and  treat  the 
defect  as  a  perforation  of  the  gut — i.  e.,  sew  up  the  hole  that  is  left  in  the  colon 
by  a  row  of  through-and-through  sutures  covered  by  a  series  of  continuous 
Lembert  sutures. 

Method  E. — Dawbarn  applies  a  purse-string  suture  of  fine  silk  or  hemp 
through  the  serous  and  muscular  coats  of  the  colon  around  the  base  of  the  ap- 
pendix, and  about  one-half  inch  distant  from  it  (Fig.  496) ;  cuts  off  the  appen- 
dix, leaving  a  stump  one-half  inch  in  length;  dilates  the  lumen  of  the  stump, 
crushes  the  stump  with  a  heavy  forceps  and  then  invaginates  the  stump  into 
the  colon,  at  the  same  time  lightening  and  tying  the  purse-string  suture. 

To  facilitate  insertion  Dawbarn  suggests  picking  up  a  loop  of  the  purse- 
string  at  B  (Fig.  496) ;  when  this  loop  and  the  free  ends  of  the  thread  are  lifted 
up,  inversion  becomes  easy. 


APPENDICECTOMY. 


377 


Fig.  497  shows  a  better  method  of  using  the  purse-string  suture.  (Fabri- 
que's  method.)  The  ends  of  the  suture  being  on  opposite  sides  of  the  wound, 
permit  better  closure  of  the  wound. 

Method  F. — This  is  a  useful  variant  of  Dawbarn's  method.  Introduce  a 
purse-string  suture  as  in  Method  E.     Clamp  the  base  of  the  appendix  very 


Fig.  496. 


Fig.  497. 


firmly  with  a  strong  clamp.  Cut  away  the  appendix  flush  with  the  clamp 
and  wipe  the  cut  surface  clean.  Remove  the  clamp  which  has  thoroughly 
crushed  the  included  tissues.  With  a  dissecting  forceps  grasp  the  stump 
and  push  it  into  the  caecum.  Pull  the  purse-string  suture  tight  and  tie. 
The  needle  still  remains  attached  to  the  purse-string  suture;  with  it  unite  the 
stump  of  the  mesoappendix  to  the  caecum  at 
the  point  of  invagination  of  the  remnant  of 
the  appendix  (Fig.  498). 

Method  G. — With  forceps  crush  the  base  of 
the  appendix.  Apply  a  fine  ligature  to  the 
groove  made  by  the  crushing  forceps.  Remove 
the  appendix.  Bury  the  stump  by  means  of 
Gould's  mattress  suture. 

Step  4. — If  there  has  been  no  infection 
outside  the  appendix,  sponge  the  field  of  opera- 
tion with  moist  pads  and  close  the  wound 
without  drainage. 

The  operation  of  appendicectomy  by  any  of  the  methods  described  in 
the  preceding  paragraphs  is  suitable  particularly  in  cases  of  chronic  or  recur- 
rent disease,  and  in  those  acute  cases  subjected  to  early  operation  before  per- 
foration, or  before  periappendicular  suppuration  has  developed.  Although 
when  the  abdomen  is  opened  there  is  no  expectation  that  pus  will  be  met,  yet 
the  peritoneal  cavity  must  always  be  protected  by  gauze  pads  while  the  appen- 


FlG.  498. 


378  VERMIFORM   APPENDIX   AND    PERITONEUM. 

dix  is  being  delivered  and  removed.  The  young  operator  is  very  apt  to  be 
afraid  boldly  to  pull  the  caecum  (when  it  is  not  bound  down  by  adhesions) 
out  of  the  abdomen  while  he  operates  upon  the  appendix.  It  does  no  harm  to 
pull  out  the  ccEcum,  but  facilitates  the  work  and  renders  it  safer,  besides  avoid- 
ing a  great  deal  of  unnecessary  trauma  to  neighboring  intestines  which  gives 
rise  to  much  post-operative  pain.  The  whole  operation  of  appendicectomy 
ought,  if  possible;,  to  be  carried  out  external  to  the  belly  cavity. 

Operation  in  Acute  Suppurative  Appendicitis  without  Large  Abscess. 
—The  operation  is  very  similar  to  that  for  recurrent  disease. 

Step  I. — Incision  C,  D,  E  (page  373). 

Step  2. — Method  B  (page  375)  is  advisable,  as  the  aid  of  the  eye  is  most 
valuable.  During  the  manipulations  necessary  for  the  discovery  and  isola- 
tion of  the  appendix,  the  general  peritoneal  cavity  must  be  protected  by  pads 
of  gauze  placed  inside  the  belly-walls,  around  the  field  of  operation,  unless 
the  introduction  of  the  pads  would  spread  the  infection  which  is  already  pres- 
ent. With  the  same  object,  to  wit,  peritoneal  protection,  it  is  wise  to  avoid  the 
separation  of  any  adhesions  which  might  give  protection  and  yet  do  not  inter- 
fere with  access  to  the  appendix.  While  isolating  the  appendix  and  breaking 
down  adhesions  larger  or  smaller  pockets  of  pus  may  be  encountered.  The 
contents  of  such  must  be  carefully  removed  by  sponging  before  further  progress 
is  attempted.  The  appendix,  having  been  recognized  and  isolated,  is  found 
to  be  acutely  inflamed,  generally  rigid,  often  rotten,  and  sometimes  perforated 
or  gangrenous.  It  must  be  removed.  Its  stump  must  be  treated  either  by 
Methods  A  or  B  or  by  Method  D  (page  375).  Method  D  is  chosen  if  the 
stump  is  too  soft  and  friable  to  hold  a  ligature.  The  appendix  being  out 
of  the  way,  a  gentle  search  is  made  for  other  pockets  of  pus;  if  such  are  found, 
they  are  treated  as  already  described.  The  whole  field  of  operation  is  most 
carefully  cleansed  with  sponges  soaked  in  normal  salt  solution.  The  protec- 
tive pads  surrounding  the  field  of  work  are  removed  and  a  split  rubber  tube 
or  a  cigarette  drain  is  passed  down  to  the  bottom  of  the  abscess  cavity.  The 
drain  may  be  brought  out  through  a  stab  wound  and  the  original  wound 
closed  completely.  Occasionally  instead  of  using  tubular  or  cigarette  drains 
the  whole  infected  area  may  be  loosely  filled  with  strips  of  plain  or  iodoform  gauze 
the  ends  of  which  come  out  at  the  wound.  As  much  of  the  abdominal  wound 
as  is  not  required  to  provide  for  drainage  and  future  access  to  the  field  of  con- 
tamination is  sutured  with  silkworm-gut.  Very  abundant  aseptic  dressings 
are  applied.  The  outer  dressings  will  generally  be  found  soaked  with  dis- 
charge within  twelve  hours  and  must  then  be  changed. 

Operation  in  Appendicitis  with  Large  Localized  Abscess. — Access 
to  the  abscess  is  usually  obtained  by  Method  F,  G  or  H  (page  374).  The 
external  incision  is  especially  good  because  the  pus  must  generally  be  sought 
to  the  outer  side  of  the  caecum.  When  cutting  through  the  parietes,  oedema 
of  the  tissues  may  be  noticed.  If  any  part  of  the  wound  shows  more  evidence 
of  oedema  than  another,  one  may  be  sure  that  pus  is  not  far  distant,  and  that 


APPENDICEAL   ABSCESS.  379 

the  oedematous  tissues  will  act  as  a  guide  to  it.  When  the  abscess  is  reached 
it  must  be  opened  with  great  care.  For  this  purpose  blunt  dissection  or  scratch- 
ing with  a  director  are  safe.  The  danger  of  opening  some  adherent  intestine 
must  not  be  forgotten.  A  small  opening  having  been  made  into  the  abscess, 
it  is  enlarged  by  blunt  force.  Enlarging  the  opening  into  the  abscess  by  means 
of  cutting  with  scissors  or  knife  is  improper  if  it  can  be  avoided.  Many  care- 
ful surgeons  end  the  operation  at  this  stage,  contenting  themselves  with  the 
introduction  of  a  drainage-tube  and  perhaps  some  gauze  packing.  They 
apply  generous  dressings  which  are  soon  soaked  with  discharge  and  must 
be  changed.  The  practice  is  safe.  Other  surgeons  explore  the  abscess  cavity 
with  the  finger  so  as  to  remove  any  faecal  concretions  or  find  the  appendix. 
Often  the  appendix  has  sloughed  and  lies  free  in  the  pus.  Great  care  must 
be  taken  to  avoid  breaking  down  any  protecting  adhesions,  other^^se  the  gen- 
eral peritoneum  may  become  infected.  If  the  appendix  is  found  attached  to 
the  CEBCum  and  can  be  isolated  without  too  great  danger,  it  should  be  removed 
and  its  stump  treated  as  already  described.  If  it  cannot  be  found  without 
prolonged  search,  or  if  its  isolation  would  endanger  the  integrity  of  the  wall 
of  adhesions  protecting  the  peritoneal  cavity,  most  surgeons  let  it  alone.  A 
few  operators  insist  that  the  appendix  should  always  be  removed,  but  to  the 
writer  this  appears  an  eminently  unsafe  doctrine.  The  abscess  cavity  is 
gently  but  thoroughly  wiped  with  gauze  moistened  in  warm  salt  solution, 
and  loosely  packed  with  iodoform  gauze,  which  may  surround  a  rubber  drain- 
age-tube. Frequently  a  sponge  stick  may  be  passed  from  the  abscess  into  the 
true  pelvis,  where  another  pocket  of  pus  may  be  found.  Remember  that 
infection  may  pass  up  the  ascending  colon  and  give  rise  to  subhepatic,  sub- 
phrenic, or  even  pleural  suppuration.  Abundant  external  dressings  are  applied. 
The  after-treatment  is  the  same  as  that  required  for  any  other  abscess.  To 
the  inexperienced  it  is  astonishing  at  times  to  see  the  amount  of  pus  obtained 
in  such  cases  when  there  has  been,  as  is  commonly  the  case,  no  fluctuation  and 
the  tumor  has  been  small.  Cases  such  as  have  been  described  very  frequently 
heal  slowly,  and  most  stubborn  sinuses  may  persist  and  require  subsequent 
operation.  When  healing  takes  place,  the  scars  are  not  very  resistant  to  pres- 
sure, hence  post-operative  herniae  are  not  uncommon. 

If  the  appendix  has  not  been  removed  when  the  abscess  was  opened,  it 
ought  to  be  sought  and  extirpated  after  recovery  has  been  obtained.  This 
secondary  operation  gives  an  opportunity  to  repair  any  hernia  which  may  be 
present.  It  has  been  stated  dogmatically  that  the  appendix  is  absolutely 
destroyed  in  the  vast  majority  of  cases  in  which  abscess  has  formed.  Mori- 
son,  however,  finds  that  in  90  per  cent,  of  instances  the  appendix  is  not  des- 
troyed but  soon  recovers  after  its  contents  have  been  discharged  by  slough- 
ing or  perforation. 

The  foregoing  description  of  operation  when  large  abscess  is  present  pre- 
supposes the  possibility  of  gaining  access  to  the  abscess  without  opening  the 
peritoneal  cavity.     Frequently  an  abscess  forms,  is  surrounded  by  adherent 


380  VERMIFORM  APPENDIX  AND   PERITONEUM. 

intestines,  omentum,  and  a  great  mass  of  exudate,  but  is  at  no  point  adherent 
to  the  anterior  parietes.  To  gain  access  to  the  tumor  it  is  necessary  to  open 
the  peritoneal  cavity  and  the  pus  must  be  evacuated  by  the  transperitoneal 
route.  In  such  cases  the  abdomen  is  opened  directly  over  the  tumor;  the  re- 
lations of  the  tumor  are  discovered  by  the  finger  used  with  the  utmost  delicacy; 
the  peritoneal  cavity  is  most  carefully  and  thoroughly  protected  by  pads  of 
gauze;  a  line  of  cleavage  is  found  in  the  tumor  and  the  finger  is  made  to  enter 
the  abscess  cavity.  The  opening  into  the  abscess  should  not  be  made  large 
at  first  or  the  whole  wound  and  packing  will  be  flooded  by  pus.  It  is  desirable 
that  the  pus  escape  so  slowly  that  it  can  be  wiped  away  at  once  with  gauze. 
After  most  of  the  pus  has  been  removed,  the  opening  into  the  abscess  may  be 
enlarged  and  the  interior  cleaned  as  well  as  possible  with  moist  gauze.  If 
the  appendix  is  easily  found,  it  should  be  removed.  Now,  the  abscess  may  be 
drained  by  a  tube  or  loose  gauze  packing.  The  protective  gauze  packs  ought 
not  to  be  disturbed,  although  their  outer  portions  may  be  partially  cut  away 
or  cleaned  as  well  as  possible.  If  these  packs  have  served  the  purpose,  while 
their  outer  surface  is  filthy  their  inner  is  clean,  and  before  sufficient  infection 
to  do  harm  can  penetrate  to  their  inner  surface,  nature  will  have  thrown  around 
them  a  barrier  of  exudate  sufficient  to  protect  the  peritoneum.  If  after  clean- 
ing the  abscess  cavity,  we  take  out  the  &i\h.y-looking  protective  packing  and 
replace  it  by  fresh  gauze,  we  almost  inevitably  push  into  the  peritoneum  a 
large  amount  of  infective  material.  The  author,  except  when  coerced  by 
symptoms,  leaves  the  protective  packing  in  situ  for  a  week  or  even  longer;  the 
loose  packing  which  drains  the  abscess  is,  of  course,  changed  as  early  and 
as  often  as  may  be  necessary.  "WTien  much  gauze  has  been  used  in  the  above 
fashion,  it  may  be  impossible  to  close  any  part  of  the  wound  with  stitches. 
This  is  of  little  importance,  as  it  is  easy,  when  suppuration  has  ceased,  to 
freshen  the  wound  and  close  it  layer  by  layer  with  sutures,  thus  lessening  the 
danger  of  having  a  post-operative  hernia. 

Operation  for  General  Peritonitis  Secondary  to  Appendicitis. — The 
object  of  operation  is  to  prevent  further  leakage  of  septic  material  into  the 
peritoneum,  to  remove  as  much  as  possible  of  the  septic  material  already  pres- 
ent, and  to  provide  for  drainage.  The  patients  are  suffering  not  merely  from 
inflammation  itself,  but  from  shock  and  intense  intoxication. 

The  Operation. — Make  a  large  incision  in  the  right  inguinal  region  over 
the  seat  of  the  appendix.  Remove  the  appendix.  Frequently  the  inflamma- 
tion has  been  so  acute  that  no  adhesions  are  present;  if  there  are  any,  they 
should  be  broken  down  to  permit  of  more  thorough  flushing.  With  wet 
sponges  mop  away  all  foreign  material,  such  as  fcccal  concretions,  etc.,  which 
may  be  found  in  the  peritoneal  cavity.  Systematically  douche  the  peritoneum 
with  a  large  stream  of  hot  normal  salt  solution.  The  solution  should  be  of 
such  a  heat  that  the  hand  can  be  kept  immersed  in  it  without  discomfort  (118° 
F.).  The  solution  may  be  poured  from  a  pitcher,  but  it  is  better  to  conduct 
it  by  means  of  large  tubing  to  the  furthest  recesses  of  the  abdomen,  so  that  the 


PERITONITIS.  381 

flow  of  contaminated  solution  may  be  outwards.  When  the  solution  returns 
clean,  the  abdominal  subcavities — e.  g.,  Douglas's  cul-de-sac  and  the  sub- 
renal cavities — are  to  be  gently  mopped  dry  with  gauze  pads.  Drains  of 
iodoform  gauze  are  introduced  into  the  various  recesses  of  the  peritoneum 
and  among  the  intestinal  loops.  If  desired,  the  gauze  strips  may  be  supple- 
mented by  glass  or  rubber  tubes  leading  to  Douglas's  pouch,  etc.,  or  counter- 
openings  may  sometimes  be  made  on  the  opposite  side  or  in  the  loins.  Abun- 
dant aseptic  dressings  must  be  applied.  The  external  dressings  will  be  found 
soaked  with  discharge  in  a  few  hours  and  must  be  changed.  The  iodoform 
gauze  drains  are  not  removed  for  at  least  forty-eight  hours.  If  a  glass  tube 
has  been  used,  it  must  be  aspirated  at  intervals  of  a  few  hours  and  removed 
generally  in  thirty-six  to  forty-eight  hours. 

Joseph  A.  Blake  ("Transactions  Am.  Surg.  Association,"  1903)  advocates 
early  operation;  lavage  of  the  peritoneum  with  large  quantities  of  saline  solu- 
tion; closure  of  the  peritoneal  cavity  ivithout  drainage,  unless  the  latter  is  abso- 
lutely indicated  by  the  presence  of  non-absorbable  amounts  of  necrotic  ma- 
terial.    Blake's  published  results  are  remarkably  good. 

One  of  the  gravest  dangers  in  generalized  peritonitis  is  the  absorption 
of  toxins  into  the  circulation.  The  peritoneum  of  the  upper  part  of  the  abdo- 
men has  greater  absorbing  power  than  that  of  the  lower,  hence  to  let  gravity 
aid  in  drainage  and  to  hinder  absorption  as  much  as  possible,  Fowler  recom- 
mends that  patients  be  kept  in  an  inclined  position,  the  upper  end  of  the  bed 
being  raised.  The  principle  of  this  is  admirable  and  good  results  have  followed 
its  use  by  most  surgeons. 

A  method  of  operating  followed  by  some  surgeons  in  cases  of  early  general- 
ized peritonitis  is  to  open  the  abdomen  in  or  near  the  middle  line.  Guided 
by  the  hand  inside  the  abdomen  it  is  easy  to  make  an  opening  about  i  1/  2  inches 
in  length  in  each  inguinal  region  and  through  these  to  insert  split  rubber  tubes 
containing  strands  of  iodoform  gauze.  Rapidly  cleanse  the  abdomen  with 
salt  solution  and  close  the  median  wound.  Return  the  patient  to  bed  and 
keep  him  propped  by  bed-rest  and  pillows  in  a  greatly  exaggerated  Fowler 
position.     The  results  obtained  are  said  to  be  excellent. 

Le  Conte  ("Annals  of  Surg.,"  February,  1906),  struck  by  the  superiority 
of  the  results  obtained  by  Murphy  over  those  in  his  own  very  eihcient  hands, 
has  adopted  practically  in  toto  the  methods  of  the  Chicago  surgeon  when 
dealing  with  diffuse  septic  peritonitis.     The  essentials  of  the  technic  are: 

1.  Rapid  elimination  of  the  cause  of  the  peritonitis  (gangrenous  appendix, 
rupture  of  gut,  rupture  of  pus  tube,  etc.).  This  with  the  least  possible  hand- 
ling of  the  viscera. 

2.  Tubular  drainage  of  the  lowest  portion  of  pelvis  through  a  suprapubic 
opening  and  free  drainage  through  the  operative  incision. 

3.  Elimination  of  all  time-consuming  procedures  at  the  time  of  operating. 
Do  not  attempt  to  clean  the  peritoneum  by  mopping  or  flushing. 

4.  Fowler's  position  after  operation. 


382  VERMIFORM  APPENDIX  AND   PERITONEUM. 

5.  Absorption  of  large  quantities  of  salt  solution  through  the  rectum. 
This  reverses  the  current  in  the  lymphatics  of  the  peritoneum,  making  the  sur- 
face of  that  membrane  a  secreting  instead  of  an  absorbing  one  and  this  also 
increases  the  secretion  of  urine.  Method  of  introducing  the  water  into  the 
rectum:  Insert  a  nozzle  containing  three  or  Jour  openings  into  the  anus.  Attach 
tubing  of  fountain  syringe  to  nozzle.  Fill  bag  of  syringe  with  water  and  ele- 
vate it  a  few  inches  above  plane  of  rectum,  in  fact  only  high  enough  to  let 
the  water  slowly  trickle  into  the  rectum  at  the  rate  of  about  one  pint  per  hour. 
Do  not  permit  fluid  to  accumulate  in  the  bowel,  just  introduce  the  water  at 
the  rate  at  which  it  is  absorbed.  Do  not  in  any  way  interfere  with  the  caliber 
of  the  tubing  (this  should  be  fairly  large).  It  is  very  important  that  there 
should  be  a  free  exchange  of  fluid  between  the  gut  and  the  water  reservoir. 
The  level  of  the  water  in  the  reservoir  should  only  be  high  enough  so  that  the 
water  in  the  rectum  merely  covers  the  end  of  the  anal  tube.  If  the  intrarectal 
pressure  increases  (due  to  gas,  etc.)  the  water  in  the  rectum  is  pressed  back 
into  the  reservoir,  the  gas,  etc.,  escapes,  and  as  soon  as  the  pressure  is  relieved 
the  water  flows  back  into  the  rectum. 

6.  Prevent  peristalsis  by  withholding  all  food  or  liquids  by  the  mouth. 
Opium  is  objectionable  but  may  be  required. 

When  ought  one  to  advise  operation  in  appendicitis? 

Many  surgeons  answer  the  above  question  in  a  most  simple  manner  by 
saying,  "When  appendicitis  is  diagnosed  then  is  the  time  to  operate."  Most 
surgeons  are  less  radical.  All  surgeons  approve  of  operating  in  the  interval 
between  attacks  of  chronic  or  relapsing  appendicitis.  In  acute  appendicitis 
all  surgeons  approve  of  operating  while  it  is  reasonable  to  suppose  that  the 
infection  is  confined  within  the  appendix  itself — i.  e.,  within  thirty-six  or  even 
forty-eight  hours  of  the  beginning  of  the  attack,  but  the  earlier  the  better.  All 
are  agreed  on  the  necessity  of  evacuating  abscesses  when  symptoms  of  absorp- 
tion are  grave  or  increasing.  In  all  other  cases  marked  differences  of  opinion 
exist.  The  author's  personal  views  are  as  follows,  and  are  those  common  to 
many  other  operators: 

1.  If  possible,  operate  within  forty-eight  hours  of  the  inception  of  the 
disease.  Within  twenty-four  hours  is  better  than  forty-eight,  and  within 
twelve  hours  is  better  than  twenty-four.     The  earlier  the  better. 

2.  After  the  lapse  of  forty-eight  hours  it  is  safer  to  adopt  Ochsner's  plan 
of  non-operative  treatment.  (Ochsner,  "Clinical  Surgery:  the  Treatment 
of  Appendicitis.")  This  consists  in — (a)  Rest  in  bed.  {b)  Avoidance  of 
purgatives,  (c)  Absolute  denial  of  food  and  drink  to  the  stomach,  {d)  If 
nausea  or  pain  is  present,  lavage  of  the  stomach,  (c)  Exclusive  rectal  ali- 
mentation (one  ounce  of  concentrated  predigested  food  in  three  ounces  of 
salt  solution,  every  four  hours).  The  exceptions  to  this  rule  are  cases  in 
young  children  and  in  the  aged.  The  former  cannot  give  the  assistance  neces- 
sary; stomach  lavage  in  them  means  a  fight  and  consequently  much  danger 
from  spread  of  infection.     Further,  the  omentum  in  children  is  small  and  can 


APPENDICITIS.  383 

do  little  to  wall  off  the  focus  of  infection.  The  aged  bear  confinement  in  bed 
badly  and  as  a  rule  the  whole  treatment  outlined  is  inapplicable  to  them.  In 
these  cases  the  surgeon  should  watch  the  case  carefully  and  if  improvement 
does  not  set  in  promptly  or  if  the  symptoms  get  worse,  he  should  operate. 

3.  After  the  subsidence  of  the  acute  attack,  where  the  temperature  and 
pulse  have  become  normal,  when  pain,  tenderness,  and  muscular  rigidity 
have  disappeared  and  the  bowels  are  acting  well,  without  causing  disturbance, 
then  the  interval  operation  ought  to  be  performed.  Many  surgeons  advise 
that  a  certain  definite  time  be  allowed  to  elapse  between  the  attack  and  the 
interval  operation,  e.  g.,  four  weeks,  to  permit  of  complete  restitution  of  the 
normal  conditions.  This  is  a  safe  precaution,  but  a  careful  observer  is  able 
to  form  an  opinion  of  his  patient's  condition  and  operate  when  he  thinks 
right  without  adhering  to  any  such  strict  rule  as  to  lapse  of  time. 

4.  When  the  case  is  seen  too  late  for  the  early  operation,  and  tumor  is 
present  and  the  pulse,  temperature,  and  general  condition  of  the  patient  indi- 
cate a  dangerous  amount  of  absorption;  if  the  tumor  is  increasing  markedly 
and  there  are  signs  of  the  infection  spreading,  no  surgeon  would  hesitate 
as  to  operation.  Interference  is  imperative.  When,  however,  the  tumor  is 
not  increasing  or  is  decreasing  and  the  temperature  and  pulse  are  moderate 
and  in  proper  relation  to  each  other,  there  is,  on  the  whole,  less  danger  in 
delay  than  in  immediate  operation.  Such  cases  almost  always  improve  under 
the  Ochsner  regimen  to  such  an  extent  that  a  safe  interval  operation  becomes 
possible.  The  danger  of  immediate  operation  is  not  merely  that  of  shock 
and  of  general  peritoneal  infection,  but  the  manipulations  necessary  for  the 
evacuation  of  the  encapsulated  pus  inevitably  open  up  channels  by  which 
toxins  are  absorbed  in  quantities  which  may  be  fatal.  Nature,  when  aided  by 
rest,  can  safely  encapsulate,  and  ultimately  remove,  even  considerable  quan- 
tities of  pus  in  the  peritoneum.  If  at  any  time  during  the  course  of  the  dis- 
ease it  becomes  apparent  that  the  encapsulation  is  incomplete  and  that  dan- 
gerous amounts  of  toxins  are  being  thrown  into  the  circulation,  then  immediate 
operation  becomes  imperative.  The  author  is  perfectly  aware  that  this  advice 
violates  the  great  law  "ubi  pus  ibi  evacuo"  and  will  not  meet  with  the  ap- 
proval of  the  majority  of  surgeons,  but  its  importance  has  been  impressed  on 
him  by  experience. 

5.  In  cases  of  appendicitis  wdth  generalized  peritonitis  the  general  rule  is 
to  operate  at  once  and  thoroughly.  Very  excellent  results  have  been  obtained 
in  this  way  by  many  thoroughly  reliable  surgeons.  The  author  is  compelled 
to  admit  that  his  recoveries  have  been  few  in  the  cases  on  which  he  has  oper- 
ated under  these  conditions,  while  of  the  cases  which  refused  operation  a 
considerable  number  (too  many  to  be  all  examples  of  mistaken  diagnosis) 
have  recovered  most  unexpectedly.  Since  adopting  the  Fowler  or,  better,  the 
exaggerated  Fowler  position  during  after-treatment,  the  writer's  results  have 
improved  immensely. 


384  VERMIFORM  APPENDIX  AND   PERITONEUM. 

TUBERCULOUS  PERITONITIS. 

When  tuberculous  peritonitis  is  not  a  mere  phase  in  the  history  of  a  general 
tuberculosis,  it  is  usually  a  reaction  against  infection  coming  from  a  tubercu- 
lous Fallopian  tube;  from  a  tuberculous  stenosing  ulcer  of  the  ileum;  from  a 
tuberculous  tumor  of  the  ileum  and  caecum;  from  a  tuberculous  vermiform 
appendix.  Tuberculous  peritonitis  is  much  more  common  in  the  female,  as 
the  Fallopian  tubes  are  the  favorite  sites  for  primary  intraabdominal  lesions. 

Accidentally  it  was  found  that  mere  abdominal  incision  and  evacuation  of 
any  ascitic  fluid  present,  with  or  without  subsequent  drainage,  led  to  recovery 
in  many  cases.  Veit  believes  that  50  per  cent,  of  the  cases  are  cured  and  25 
per  cent,  improved  after  the  above  treatment,  the  curative  agent  being  serum, 
efifused  as  a  result  of  the  operative  interference,  acting  as  an  antitoxin. 

The  most  favorable  cases  are  those  in  which  ascitic  fluid  was  removed  during 
the  operation,  hence  it  is  difficult  to  imagine  the  above  theory  correct.  J.  B. 
Murphy  observed  that  where  the  end  of  the  diseased  Fallopian  tube  was  patent, 
peritonitis  was  progressive,  and  where  the  ostium  was  closed  by  adhesions, 
etc.,  the  peritonitis  became  stationary  or  was  cured.  Mayo  came  to  the  con- 
clusion that  in  the  presence  of  ascites  the  fimbriated  extremity  of  the  tube 
was  mechanically  kept  patent,  the  fimbriae  being  kept  from  adhering  to  each 
other  and  to  neighboring  structures,  and  hence  the  infective  contents  of  the 
tube  could  constantly  or  intermittently  leak  into  the  peritoneal  cavity.  This 
gives  a  feasible  explanation  as  to  why  simple  laparotomy  with  removal  of 
ascitic  fluid  often  results  in  the  cure  of  tuberculous  peritonitis;  the  end  of  the 
tube,  no  longer  buoyed  up  by  the  fluid,  becomes  closed,  either  by  the  fimbriae 
adhering  to  each  other  or  to  neighboring  structures.  The  primary  lesion 
thus  becomes  encapsulated,  and  the  peritoneum,  being  very  resistant  to  tuber- 
culosis, recovers.  It  has  long  been  known  that  the  cases  accompanied  by 
ascites  are  the  ones  most  benefited  by  surgical  interference. 

Primary  tuberculous  lesions  in  the  ileum  have  a  great  tendency  towards 
spontaneous  recovery;  in  these,  when  operation  is  demanded,  it  is  to  overcome 
resultant  stenosis. 

The  tumor-like  tuberculosis  of  the  ileo-caecal  region  has  likewise  a  predis- 
position to  cure.  Both  in  the  case  of  disease  of  the  ileum  and  of  the  ileo- 
caecal  region  the  presence  of  ascites  is  well  calculated  to  prevent  the  formation 
of  protective  adhesions  around  the  focus  of  disease,  hence  the  simple  removal 
of  the  fluid  may  result  in  efficient  encapsulation  of  the  primary  focus. 

Baisch  ("Munch,  med.  Woch.,"  20  Aug.,  1907)  reports  the  results  in  one 
hundred  and  ten  cases  of  tuberculous  peritonitis  observed  from  four  to  ten 
years  in  the  Tiibingan  gynecological  clinic. 

1.  Pure  Exudative  Form. — Thirty-eight  cases;  thirty-four  submitted  to 
operation,  twenty-two  cured,  twelve  of  those  operated  on  died  in  from  three 
months  to  four  years. 

2.  Dry  Adhesive  Form. — Twenty-two  cases;  eleven  submitted  to  opera- 


TUBERCULOSIS.  385 

tion,  eight  of  whom  remained  well,  a  few  of  these  recovered  only  after  a  long 
illness  and  two  had  fecal  6stula  which  closed  after  some  months. 

3.  Tuberculous  Adnexae. — Forty-five  cases;  thirty-two  submitted  to  opera- 
tion with  good  results  (eighteen  cured;  five  in  which  one  tube  was  left  required 
a  secondary  operation).  Do  not  leave  an  apparently  healthy  Fallopian  tube. 
Leave  the  uterus  and  if  an  ovary  appears  healthy  it  may  safely  be  left. 

Operative  Treatment. — It  is  presumed  that  the  diagnosis  of  tuberculous 
peritonitis  has  been  made,  but  the  site  of  the  primary  lesion  is  unknown. 

Step  I. — Open  the  abdomen,  in  the  female,  by  median,  in  the  male,  by 
the  right  rectus,  incision.     Evacuate  any  fluid  which  may  be  present. 

Step  2. — If  in  the  female,  examine  the  Fallopian  tubes.  This  must  be 
done  with  enormous  caution  in  the  presence  of  many  adhesions,  as  it  is  easy 
to  tear  into  a  gut.  If  the  necessary  manipulations  are  very  difficult,  the  dan- 
gers from  injury  to  the  gut  outweigh  the  advantages  of  a  radical  removal  of 
the  primary'  focus,  and  it  will  be  wise  for  most  surgeons  to  trust  to  the  encap- 
sulation of  the  disease  which  is  likely  to  result. 

If  safe,  removal  of  the  tubes  is,  of  course,  the  procedure  of  choice.  In 
any  case  examine  the  favorite  sites  of  tuberculous  lesions.  Remember  that 
what  may  appear  a  simple  chronic  appendicitis  may  be  tuberculous,  and  that 
with  the  appendix  any  enlarged  glands  in  the  mesenteriolum  ought  to  be 
removed.  WTien  there  is  a  stenosing  ulcer  of  the  ileum,  an  anastomosis  be- 
tween the  afferent  and  efferent  segments  of  gut  is  all  that  is  commonly  re- 
quired. If  the  diseased  segment  of  gut  is  limited  in  extent  and  easily  ex- 
cised, its  removal  is  proper,  though  not  imperative. 

The  tumor-like  tuberculous  lesion  of  the  ileo-caecal  region  ought  to  be 
excised  if  this  is  fairly  easy;  if  difficult,  then  that  segment  of  the  gut  may  be 
"segregated"  (see  page  349)  or  left  to  the  curative  powers  of  nature,  assisted 
by  the  abdominal  incision. 

M.  H.  Richardson  writes:  "When,  therefore,  I  have  found  a  tuberculosis 
limited  to  a  single  coil  of  intestine,  rather  than  excise  that  coil,  except  when 
stricture  is  present,  I  have  contented  myself  with  the  exploration  and  demon- 
stration of  the  disease.  If  the  area  affected  has  been  one  that  could  be  easily 
and  safely  removed,  I  have  removed  it,  as  in  tuberculosis  limited  to  the  appen- 
dix or  to  the  Fallopian  tubes." 

In  one  case  operated  on  by  the  author  three  enlarged  lymph  nodes,  one 
the  size  of  a  hen  egg,  existed  in  the  mesentery  of  the  ileum.  There  was  no 
evident  disease  of  the  gut.  Incision  through  the  superficial  layer  of  the  mes- 
entery permitted  the  easy  enucleation  of  the  diseased  structures,  after  which 
the  mesenteric  wound  was  sutured.     Recovery. 

Any  tuberculous  abscesses  encountered  should  be  evacutated,  dried,  iodo- 
formized,  and  not  drained. 

Step  3. — Close  the  abdomen,  preferably  without  drainage.  The  use  of  a 
drain  is  liable  to  lead  to  secondary  infection  and  faecal  fistula. 

25 


CHAPTER  XXXIV. 
THE  RECTUM. 

Imperforate  Anus. — There  are  two  forms  of  imperforate  anus,  (A)  No 
anal  depression  is  present;  (B)  an  anal  depression  is  present,  but  does  not  open 
into  the  rectum. 

(A)  The  anal  depression  is  absent. 

The  Operation. — ^Place  the  child  in  the  lithotomy  position.  Draw  off  the 
urine  with  a  catheter.  Do  not  keep  the  patient  deeply  anaesthetized,  as  its  at- 
tempts at  crying  and  struggling  press  the  gut  downwards  and  aid  the  sur- 
geon in  recognizing  the  gut  when  he  approaches  it.  Of  course,  enough  an- 
aesthetic should  be  given  to  prevent  suffering. 

Step  I. — Make  an  incision  in  the  median  line  from  the  middle  of  the  peri- 
neum to  the  tip  of  the  coccyx.  Penetrate  the  skin  and  the  musculo-aponeurotic 
floor  of  the  pelvis.  Frequently  the  gut  will  now  present  and  be  recognized 
from  the  dark  blue  color  given  it  by  the  contained  meconium.  If  the  gut  is 
not  found,  retract  the  walls  of  the  wound.  Note  the  position  of  the  bladder — 
if  necessary,  introducing  a  sound  into  the  bladder  for  this  purpose.  Deepen 
the  wound  by  blunt  dissection,  following  the  concavity  of  the  sacrum  to  its 
promontory.  If  the  external  wound  is  too  small  to  permit  of  such  deep  dis- 
section, continue  the  original  incision  backwards  over  the  lower  end  of  the 
sacrum  and  excise  the  coccyx  and  lowest  segment  of  the  sacrum.  When  the 
neighborhood  of  the  gut  is  reached,  if  the  child  cries,  an  impulse  will  be  com- 
municated to  the  palpating  finger.  If  the  child  is  too  deeply  anaesthetized  to 
cry,  intermittent  firm  pressure  on  the  abdomen  may  give  the  same  result.  The 
gut  having  been  found,  separate  its  lower  end  as  freely  as  possible  from  its 
surroundings. 

Step  2. — When  the  gut  is  found  to  be  superficial,  seize  it  with  a  couple  of 
small  volsellum  forceps  or  pass  a  suture  through  it  for  purposes  of  traction 
and  pull  it  downwards  to  the  skin,  separating  its  lateral  adhesions  as  traction 
is  being  made.  With  a  knife  cut  into  the  gut.  Meconium  at  once  escapes 
and  must  be  washed  away  by  a  stream  of  warm  water.  Clean  out  the  gut 
by  means  of  injections  of  warm  water  until  the  water  returns  clear.  Cleanse 
the  wound  with  a  mild  antiseptic  solution. 

Step  3. — Carefully  and  accurately  suture  the  opening  in  the  gut  to  the 
skin  with  interrupted  sutures.     Close  the  remainder  of  the  wound  with  such 
deep  and  superficial  sutures  as  may  be  required. 

When  the  gut  is  more  deeply  situated,  the  technic  is  rendered  much 
more  difl&cult.     It  may  be  impossible  to  bring  the  gut  down  to  the  skin  before 

386 


PROLAPSUS   RECTI.  387 

evacuating  its  contents.  In  such  a  case,  fix  the  gut  with  sharp  hooks  or  for- 
ceps, open  it  with  a  knife,  and  by  means  of  a  catheter  douche  out  its  contents. 
When  the  gut  has  been  emptied,  it  is  often  possible  to  separate  it  from  its 
lateral  connections  and  bring  it  down  to  or  near  to  the  skin.  WTien  possible, 
the  edges  of  the  opening  in  the  gut  must  be  accurately  sutured  to  the  skin,  as 
already  described. 

Should  the  rectum  be  entirely  absent,  the  peritoneal  cavity  may  be  opened 
through  the  perineal  wound  and  the  first  loop  of  gut  which  presents  (gen- 
erally the  sigmoid)  brought  down,  opened,  and  sutured  to  the  skin  (Stromeyer). 
In  cases  of  failure  to  find  the  lower  end  of  the  rectum  through  the  perineal 
route  Macleod  recommends  that  the  abdomen  be  opened,  the  lower  end  of  the 
blind  rectum  found,  rendered  mobile,  and  pushed  downwards  into  the  perineal 
wound,  where  it  is  treated  in  the  manner  already  described. 

(B)  The  anal  portion  of  the  gut  is  present,  but  is  not  joined  to  the  rectum. 

By  palpation  and  inspection  find  if  there  is  only  a  thin  diaphragm  separat- 
ing the  rectum  from  the  anal  gut  or  depression.  If  this  is  so,  perforate  or 
excise  the  diaphragm.  If,  as  is  often  the  case,  much  tissue  is  interposed^ 
make  an  incision  in  the  middle  line  from  the  anal  depression  or  gut  to  the 
coccyx,  deepen  the  incision  as  may  be  required,  and  proceed  as  if  no  anal 
gut  were  present,  except  that  after  the  rectum  has  been  opened  and  evacuated, 
its  opening  should  be  sutured  to  the  anal  gut  instead  of  to  the  skin. 

A\Tien  none  of  the  methods  described  is  successful,  or  if  the  condition  of 
the  patient  is  such  as  to  render  the  operation  hazardous,  it  is  proper  to  make 
a  permanent  or  temporary  artificial  anus  in  the  inguinal  or  lumbar  region. 
Should  it  seem  advisable,  the  perineal  operation  may  be  attempted  as  a 
later  date. 

Prolapsus  Recti. — Rectal  prolapse  may  be  of  two  forms:  in  one  form  the 
rectal  mucous  membrane  alone  is  protruded  through  the  anus;  in  another, 
the  rectal  walls  are  more  or  less  prolapsed.  The  prolapsed  tissue  may  be 
reducible  or  irreducible;  in  the  latter  case  it  generally  shows  evidences  of  past 
and  present  inflammation.  The  prolapse  may  be  due  to  atony  or  dilatation 
of  the  sphincter,  or  to  a  lack  of  support  to  the  gut  from  above.  Prolapse  may 
be  an  accidental  concomitant  of  a  rectal  tumor,  the  weight  of  the  tumor  drag- 
ging the  gut  down.  Comparatively  recently  the  main  active  treatment  of  rec- 
tal prolapse  consisted  in  chemical  or  thermal  destruction  of  protruding  mucous 
membrane  or  of  portions  of  the  dilated  anus,  the  scar  contraction  incident 
to  healing  leading  to  narrowing  of  the  anus  and  support  of  the  gut.  Strangu- 
lation of  the  protruding  tissues  by  means  of  ligatures  was  also  recommended 
and  often  gave  good  results.  All  such  measures  ought  to  be  discarded,  as 
chemical  and  thermal  action  is  diflficult  to  regulate  and  the  strangulation 
by  ligature  is  distinctly  dangerous.  There  are  three  distinct  principles,  each 
of  which  is  the  base  is  of  a  modem  method  of  operative  treatment. 

I.  When  the  prolapse  is  due  to  sphincteric  atony  or  looseness,  the  principle 
of  treatment  is  to  overcome  this  condition  by  narrowing  the  sphincter. 


305  THE    RECTUM. 

2.  When  the  prolapse  is  due  to  want  of  superior  support,  such  support 
must  be  provided. 

3.  When  there  is  excess  of  rectum  and  much  tissue  is  prolapsed,  the  pro- 
truded mass  should  be  excised.  Generally  this  excision  must  be  supplemented 
by  narrowing  the  sphincter. 

It  must  be  remembered  that  very  many  cases  of  prolapse,  and  in  children 
even  severe  cases,  may  be  cured  without  operative  interference. 

Plastic  Operation  on  the  Sphincter  Ani. — I.  Dtiret's  Operation. — From  the 
posterior  surface  of  the  rectum  remove  a  triangle  of  mucous  membrane.  The 
base  of  the  triangle  is  at  the  muco-cutaneous  junction;  the  apex  is  directed 
up  to  the  gut.  From  the  skin  behind  the  anus  remove  a  similar  triangle  having 
the  same  base  as  the  former,  but  having  its  apex  directed  towards  the  coccyx. 
A  lozenge-shaped  raw  surface  is  thus  formed  partly  involving  the  skin  and 
partly  the  mucosa.  By  deep  dissection  cut  away  a  wedge  of  the  tissues  ex- 
posed by  the  removal  of  the  skin  and  mucous  membrane.  With  the  wedge 
of  tissue  a  portion  of  the  sphincter  is  excised.  Insert  deep  and  superficial 
sutures  and  close  the  wound.  It  is  a  wise  precaution  to  unite  the  divided 
ends  of  the  sphincter  by  one  or  more  interrupted  buried  catgut  sutures.  In 
one  case  of  particularly  flaccid  anus  Duret  has  performed  the  above  operation 
both  posteriorly  and  anteriorly.  The  operation  must  be  done  under  the  most 
painstaking  aseptic  technic.  This  is  of  great  moment  in  all  the  plastic  opera- 
lions  about  the  rectum  and  anus. 

II.  Buret's  operation  may  be  modified  as  follows:  Make  a  curved  trans- 
verse incision  following  more  or  less  closely  the  muco-cutaneous  junction  at 
the  posterior  side  of  the  anus.  Through  this  incision,  with  scissors  or  knife 
dissect  the  mucous  membrane  from  the  posterior  anal  wall  until  a  point  is 
reached  above  the  sphincter.  Excise  a  sufficiency  of  the  sphincter  and  with 
catgut  sew  the  divided  ends  together.  If  necessary,  excise  a  portion  of  the 
reflected  flap  of  mucous  membrane.  Close  the  superficial  wound.  This 
operation  is  only  feasible  if  the  prolapse  can  be  reduced. 

Operations  to  Narrow  the  Rectal  Lumen  and  thus  Prevent  Prolapse. — 
Lange's  Operation  [Transverse  Rectorrhaphy) . — Make  an  incision  in  the  middle 
line  from  a  point  immediately  behind  the  anus  to  the  base  of  the  coccyx.  Do 
not  injure  the  sphincter.  Resect  the  coccyx.  By  dissection  expose  the  pos- 
terior surface  of  the  rectum.  Introduce  a  number  of  sutures  into  the  gut  wall 
in  the  Lembert  fashion,  transversely,  as  if  closing  a  longitudinal  tear  in  the 
rectal  wall.  The  sutures  must  not  penetrate  the  mucosa.  Tie  the  sutures. 
The  result  is  to  narrow  the  gut  by  throwing  its  posterior  wall  into  a  longitudi- 
nal fold.     Close  the  external  wound  by  deep  and  superficial  sutures. 

Rectopexy. — (A)  VernetiiVs  Operation. — With  a  knife  trace  a  triangle  hav- 
ing its  base  at  the  anus,  its  apex  at  the  tip  of  the  coccyx.  Excise  this  triangle 
of  tissue  and  with  it  the  whole  segment  of  sphincter  corresponding  to  its  base. 
Pass  a  long  suture  transversely  through  the  posterior  wall  of  the  exposed 
rectum,  without  penetrating  the  mucosa.     Arm  each  end  of  the  suture  with 


COLOPEXY.  389 

a  needle.  Push  the  needles  through  the  tissues  of  the  back,  from  within  out- 
wards, to  emerge  through  the  skin,  one  on  each  side  of  the  sacrococcygeal 
articulation.  At  lower  levels  introduce  three  other  sutures  in  a  similar  manner. 
Tie  the  sutures.  This  narrows  the  anus  and  pulls  the  lower  rectum  backwards 
and  upwards. 

(B)  Marchanfs  Operation. — Expose  the  posterior  surface  of  the  rectum 
by  means  of  a  median  incision  from  behind  the  anus  to  the  tip  of  the  coccyx. 
Introduce  several  rows  of  sutures  in  the  long  axis  of  the  gut  after  the  Lembert 
method,  as  if  to  close  a  series  of  transverse  ruptures  of  the  gut.  The  sutures 
must  not  penetrate  the  mucosa.  As  each  row  of  longitudinally  placed  sutures 
is  tied  the  posterior  wall  of  the  gut  is  thrown  into  a  series  of  transverse  folds, 
which  shortens  it.  With  catgut  unite  the  lowermost  fold  to  the  tissues  im- 
mediately in  front  of  the  coccyx.  Give  additional  support  by  introducing 
one  or  more  sutures  after  the  method  of  Verneuil  described  above.  Close 
the  wound  completely. 

Colopexotomy  {JeanneVs  Operation). — The  object  of  this  operation  is  to 
attach  the  sigmoid  flexure  to  the  abdominal  wall  and  so  give  superior  support 
to  the  rectum.  The  scope  of  the  operation  must  be  limited.  In  Garre's 
clinic  59  per  cent,  of  relapses  followed  the  operation  or  some  modification  of 
it.    (Pachnio,  "Beitriige  z.  klin.  Chir.,"  xlv,  300.) 

The  Operation. — Open  the  belly  as  in  left 
inguinal  colostomy.  Seize  the  sigmoid  flexure 
and  pull  it  up  until  the  rectal  prolapse  is  re- 
duced. Suture  to  the  abdominal  wound  the 
lowest  portion  of  the  gut  which  can  conveniently 
be  brought  into  it  after  reduction  of  the  pro- 
lapse. Make  an  artificial  anus.  After  the  gut 
is  securely  attached  to  the  abdominal  wall,  and 
the    rectum,    irritated  and  inflamed  because  of  Fig.  499. 

having  been  prolapsed,  is  healed,  the  artificial     ^  O.T.   Outer  tube  of  gut.   I.T. 
"  '■  Inner  tube  of  gut.   P.  Peritoneum. 

anus   may  be  closed.  S.  Sphincter  ani.     X.  Suture. 

Excision  of  the  Prolapsed  Gut. — A  consider- 
able number  of  methods  have  been  devised  for  the  removal  of  the  prolapsed 
mass.  Several  of  the  methods  fail  to  recognize  the  existence  of  a  peritoneal 
pouch  between  the  inner  and  outer  tube  of  the  intussuscepted  gut  and  that 
a  loop  of  small  intestine  may  be  present  in  that  pouch.  This  failure  renders 
all  such  methods  too  dangerous  to  be  justifiable,  and  they  will  not  be  here 
described. 

Mikulicz's  Operation. — Place  the  patient  in  the  lithotomy  position  at  the 
edge  of  the  table.  Make  a  horizontal  incision  through  the  anterior  half  of 
the  external  tube  or  cylinder  of  gut,  i.  e.,  into  the  peritoneal  pouch.  Explore 
the  pouch  with  the  finger  and  reduce  its  contents  if  there  are  any.  Suture, 
by  the  Lembert  method,  the  peritoneal  surface  of  the  outer  tube  to  that  of 
the  inner  tube  (Fig.  499).     Cut  away  the  gut  corresponding  and  peripheral 


390  THE    RECTUM. 

to  the  line  of  suture.  Cover  the  line  of  suture  by  a  row  of  stitches  uniting 
the  mucous  membrane  of  the  outer  to  that  of  the  inner  tube.  The  posterior 
half  of  the  prolapsed  gut  must  now  be  attacked  in  the  same  manner  and  the 
outer  and  inner  tubes  united  by  a  row  of  Lembert  sutures  protected  from  con- 
tamination by  some  stitches  which  involve  the  mucosa  alone. 

To  be  successful  the  above  operation  must  often  be  supplemented  by  a 
plastic  operation  on  the  sphincter  such  as  has  already  been  described. 

Stricture  of  Rectum. — I.  When  a  rectal  stricture  is  soft  and  can  be  reached 
through  the  anus,  treatment  by  gradual  dilatation  should  be  attempted. 

Introduction  of  Rectal  Bougies. — Place  the  patient  on  his  left  side  with  the 
right  thigh  partially  flexed.  Introduce  the  index  finger  through  the  anus  and 
locate  the  opening  through  the  stricture.  If  the  stricture  is  large  enough  to 
permit  the  passage  of  the  finger  without  force  being  employed,  the  finger  may 
be  used  as  a  bougie.  If  the  stricture  is  either  narrower  or  much  wider  than 
the  finger,  use  the  finger  as  a  guide  and  pass  a  well-oiled  soft-rubber  rectal 
bougie  through  the  constriction.  N'o  appreciable  force  must  be  used.  Leave 
the  bougie  in  place  for  two  or  three  minutes  and  withdraw  it.  Repeat  the 
operation  after  the  lapse  of  from  one  to  four  days,  i.  e.,  after  any  irritation 
produced  by  the  operation  has  subsided.  At  each  operation  it  may  be  neces- 
sary to  pass  several  instruments  of  different  sizes,  the  last  one  being  the  largest 
which  it  is  possible  to  introduce  through  the  constriction  without  force.  The 
principle  of  treatment  is  identical  with  that  of  gradual  dilatation  of  urethral 
stricture.  As  in  the  case  of  the  urethra,  some  rectal  strictures  are  too  irritable 
to  permit  of  gradual  dilatation.  When  suitable,  the  treatment  is  safe,  but  it  is 
only  palliative,  as  the  contraction  recurs  when  dilatation  is  discontinued. 

II.  Crede's  Operation. — If  the  stricture  is  firm  and  resistant  to  gradual 
dilatation,  Crede's  operation  may  be  useful.  Administer  an  anaesthetic. 
Guided  by  the  finger,  pass  a  probe-pointed  knife  through  the  stricture  and 
with  it  make  a  number  of  small  cuts  or  "nicks"  in  the  protruding  edge  or  ring 
of  the  stricture.  Six  or  eight  of  these  cuts  may  be  made,  none  of  them  deep 
enough  to  endanger  the  peritoneum.  Remove  the  knife  and  gently  introduce 
a  bougie.     The  rest  of  the  treatment  is  that  of  gradual  dilatation. 

Forcible  dilatation  has  been  practised,  but  has  proven  too  brutal  and  dan- 
gerous.    It  is  unjustifiable. 

III.  Posterior  Rectotoniy. — Place  the  patient  in  the  lithotomy  position. 
Guided  by  the  finger,  pass  a  probe-pointed  bistoury  through  the  stricture 
and  divide  it  completely  in  the  middle  line  posteriorly.  Continue  the  incision 
downwards  and  backwards  so  as  to  divide  the  sphincter  ani.  The  result  of 
this  cut  is  the  division  of  the  stricture,  the  rectal  wall  below  the  stricture,  and 
the  sphincter,  in  the  posterior  median  line.  Attend  to  hemostasis.  Pack 
the  wound.  The  after-treatment  consists  in  frequent  changes  of  dressings,  in 
careful  cleansings,  and  subsequently  in  the  use  of  rectal  bougies. 

IV.  Bean's  Modification  of  Posterior  Rectotomy. — Make  an  incision  in  the 
middle  line  of  the  posterior  wall  of  the  rectum  from  a  point  three-fourths  of 


EXCISION    OF   RECTUM,  39I 

an  inch  above  the  stricture  to  and  including  the  sphincter  ani.  Continue 
the  incision  backwards  in  the  middle  line  until  the  incision  through  the  skin 
equals  in  length  that  through  the  mucous  membrane  of  the  rectum.  Pull  the 
mucous  membrane  at  the  upper  angle  of  the  wound  downwards  and  suture 
it  to  the  skin.  To  render  the  mucous  membrane  movable,  it  may  be  necessary 
to  undermine  it  slightly.  The  principle  of  the  operation  is  to  convert  the 
original  vertical  wound  into  a  transverse  one  and  so  gain  room. 

V.  Sonnenburg's  Operation. — Expose  the  gut  by  Kraske's  method  (page 
394).  Divide  the  stricture,  vertically,  taking  care  to  avoid  injuring  the  sphinc- 
ter. Pack  the  wound.  Healing  takes  place  very  slowly;  fistulse  are  almost 
certain  to  persist,  and  after-treatment  with  bougies  is  necessary. 

VI.  Sokoloff's  Operation. — This  operation  is  the  same  as  Sonnenburg's, 
but  instead  of  packing  the  wound,  the  vertical  incision  is  converted  into  a 
transverse  one  by  means  of  sutures.  In  suitable  cases  this  operation  is  one 
of  much  promise,  but  cases  suitable  for  it  must  be  exceedingly  rare. 

VII.  Excision  of  the  Stricture. — The  stricture  may  be  excised  in  various 
ways.  The  methods  of  rectal  excision  are  described  elsewhere,  It  was  hoped 
that  excision,  though  dangerous,  might  prove  an  entirely  reliable  means  of 
treatment.  Experience  seems  to  show  that  it  is  little  better  than  a  means  of 
palliation. 

VIII.  Colo-rectostomy. — When  the  stricture  is  steated  high  up  in  the  rec- 
tum, an  anastomosis  may  be  made  between  the  colon  and  the  rectum  so  that 
the  intestinal  contents  may  pass  around  the  stricture. 

IX.  Colostomy  may  be  used  in  the  treatment  of  rectal  stricture  for  two  pur- 
poses: (a)  To  give  relief  from  the  obstruction;  {h)  to  give  rest  to  the  rectum 
and  to  permit  of  local  operations  or  treatment  being  carried  out  without  inter- 
ruption from  faeces.  In  this  case  after  the  rectal  disease  has  been  cured  the 
artificial  anus  may  be  closed. 

The  methods  of  performing  colostomy  are  described  elsewhere. 

Excision  of  Rectum. — Excision  of  the  rectum  is  most  commonly  indi- 
cated in  cases  of  malignant  tumors.  When  performed  for  the  relief  of  rectal 
stricture  (non-malignant),  the  operation  is  identical,  except  that  in  this  case 
it  is  not  necessary  to  excise  the  disease  so  extensively. 

Preliminary  Treatment. — Two  main  indications  must  be  observed,  viz.: 
(i)  Improve  the  general  condition  of  the  patient;  (2)  diminish  the  septicity 
of  the  intestine. 

The  general  condition  may  be  improved  by  means  of  proper  regulation 
of  the  organs  of  elimination  and  of  proper  regulation  of  the  diet.  A  diet  of 
eggs  and  milk  is  highly  to  be  recommended.  How  may  the  septicity  of  the 
gut  be  diminished?  The  only  efficient  medicinal  means  of  cleansing  the 
rectum  is  purgation.  But  it  is  easy  to  carry  this  means  too  far  and 
weaken  the  patient.  The  moderate  use  of  salines  or  of  calomel  is  highly 
proper.  For  Tuttle's  method  of  cleaning  the  rectum  see  page  411.  Various 
antiseptics  have  been  administered  by  the  mouth,  in  the  hope  of  lessening  the 


392  THE    RECTUM. 

filthiness  of  the  rectum  (resorcin,  salol,  etc.),  but  in  the  opinion  of  the  writer 
such  endeavors  must  be  as  futile  as  an  attempt  to  antisepticize  the  Mississippi 
River  at  New  Orleans  by  pouring  a  barrel  of  corrosive  sublimate  into  its  cur- 
rent at  St.  Paul. 

Apart  from  moderate  purgation,  the  only  possible  means  to  approximate 
cleanliness  in  the  lower  bowel  is  flushing  and  scraping. 

Flushing  the  Rectum. — Pass  a  long,  soft,  flexible  rubber  tube  into  the  rec- 
tum and  through  the  stricture.  Through  a  funnel  on  the  proximal  end  of 
the  tube  pour  warm  water  or  boracic  acid  solution  into  the  gut  until  the  patient 
experiences  a  feeling  of  discomfort.  Lower  the  funnel  and  tube,  and  permit 
the  water  to  flow  into  a  receptacle  on  the  floor.  Repeat  the  operation.  Carry 
out  these  rectal  flushings  every  morning  and  evening  for  four  or  five  days 
before  the  operation. 

Scraping  the  Rectum. — Immediately  before  the  operation  dilate  the  anus 
and  scrape  away  all  the  friable  surface  of  the  cancerous  growth  with  a  sharp 
spoon,  preferably  with  a  flushing  curette.  The  bleeding  is  trivial  and  soon 
stops.  Should  the  hemorrhage  not  cease  spontaneously  and  quickly,  touch 
the  bleeding  points  with  a  thermo-cautery  or  with  liquid  carbolic  acid,  pref- 
erably the  former.  Removal  of  the  abominably  foul  surface  of  the  cancer 
with  a  curette  and  thorough  flushing  of  the  rectum  are  undoubtedly  the  best 
means  of  diminishing  the  septicity  of  the  bowel,  but  however  thoroughly 
these  means  are  used,  the  cleanliness  obtained  is  only  relative,  though  none 
the  less  important. 

I.  Vaginal  Route. — In  the  female,  when  the  anterior  rectal  wall  alone  is 
diseased,  one  may  make  a  vertical  incision  through  the  posterior  vaginal  wall, 
expose  the  growth,  excise  it,  suture  the  opening  left  in  the  rectum,  and  then 
separately  suture  the  vaginal  wound.  Such  an  operation  is  not  often 
suitable. 

II.  Anal  Route. — (A)  The  anus  is  involved  in  the  disease.  Place  the 
patient  in  the  lithotomy  position.  Make  an  incision  all  around  the  anus. 
With  blunt  and  sharp  dissection  separate  the  diseased  anus  and  the  rectum 
from  their  surroundings  until  a  point  in  the  rectum  is  reached  about  one  and 
one-half  inches  above  the  disease.  Divide  the  rectum  at  this  point  and 
remove  the  disease.  Attend  to  hemostasis.  Pull  the  edge  of  the  divided 
rectum  downwards  and  suture  it  to  the  skin,  if  possible.  If  the  incision  sur- 
rounding the  anus  does  not  give  sufficient  room  for  the  next  steps  of  the 
operation,  one  may  supplement  it  by  a  median  incision  running  backwards 
to  the  coccyx  or  one  may  even  excise  the  coccyx.  If  it  is  impossible  to  bring 
the  divided  end  of' the  rectum  down  to  the  skin  at  the  site  of  the  natural  anus, 
it  may  be  sutured  to  the  skin  at  the  level  of  the  coccyx. 

The  operation  as  described  is  permissible  only  if  the  anus  is  diseased. 
The  sphincter  is  sacrificed.  Incontinence  of  faeces  results.  Delbet  writes: 
"To  avoid  these  inconveniences  Witzel,  on  the  advice  of  Willems,  passes 
the  end  of  the  rectum  through  the  fibres  of  the   gluteus  maximus,  Rydgier 


EXCISION    OF   RECTUM.  393 

through  the  pyriformis  and  gluteus  maximus,  Gersuny,  before  fixing  the  rec- 
tum, so  twists  it  on  its  axis  that  its  longitudinal  muscular  fibres  play  the  role 
of  sphincter,  or  at  least  offer  some  mechanical  opposition  to  the  escape  of 
intestinal  contents." 

(B)  The  anus  is  not  involved  in  the  disease. 

1.  The  disease  is  freely  movable  and  only  involves  a  small  part  of  the 
rectal  wall.  Place  the  patient  in  the  lithotomy  position.  Dilate  the  anus 
fully.  Seize  the  tumor  with  a  volsellum  and  pull  it  downwards  into  a  freely 
accessible  position.  On  each  side  of  and  a  little  above  the  tumor  seize  the 
rectum  with  forceps  or  sharp  hooks.  The  object  of  this  is  to  prevent  the 
wound  being  retracted  out  of  easy  reach  after  the  tumor  is  removed.  Freely 
excise  the  tumor.  Close  the  wound  with  sutures  after  attending  to  hemostasis. 
When  possible,  it  is  wise  to  insert  the  sutures  in  the  long  axis  of  the  gut  so  that 
the  resulting  scar  is  transverse  and  danger  of  subsequent  stricture  is 
lessened. 

2.  The  disease  is  freely  movable,  is  very  low  down  in  the  rectum,  but 
involves  all  or  nearly  all  the  circumference  of  the  gut.  Place  the  patient  in 
the  lithotomy  position.  DUate  the  anus  fully.  Seize  the  tumor  with  volsellum 
forceps  and  pull  it  downwards  into  a  freely  accessible  position.  Make  an 
incision  completely  around  the  anus  at  the  muco-cutaneous  junction.  Sepa- 
rate the  anal  mucous  membrane  from  the  sphincter.  When  the  upper  edge 
of  the  sphincter  is  passed,  divide  the  whole  thickness  of  the  rectal  wall  and 
separate  the  rectum  from  its  surroundings  until  a  point  is  reached  well  above 
the  disease.  In  cancer  remove  two  much  rather  than  too  little.  Attend  to 
hemostasis.  Divide  the  rectum  above  the  disease  and  remove  it.  Pull  down 
the  divided  end  of  healthy  rectum  and  suture  it  to  the  skin. 

III.  The  Perineal  Route. — Place  the  patient  in  the  lithotomy  position. 
Make  an  incision  in  the  middle  line  from  the  anus  to  the  point  of  the  coccyx. 
This  incision  divides  the  sphincter.  Dieffenbach  supplements  the  above 
cut  by  one  placed  in  the  middle  line  anteriorly  which  also  divides  the  sphincter 
and  reaches  to  the  bulb  of  the  urethra.  Retract  the  edges  of  the  wound. 
Separate  the  anal  mucous  membrane  from  the  sphincter  and  proceed  to  remove 
the  disease  as  described  in  the  preceding  paragraph.  In  dissecting  the  rectum 
free  from  its  surroundings  take  special  care  not  to  injure  the  prostate  or  the 
base  of  the  bladder;  for  this  purpose  it  is  wise  to  do  most  of  the  dissection 
with  the  finger  or  some  blunt  instrument.  Should  the  bladder  be  torn,  its 
wound  must  be  closed  at  once  by  a  few  sutures. 

The  disease  having  been  removed,  pull  down  the  divided  end  of  the  healthy 
rectum  and  suture  it  to  the  anal  skin.  Close  the  rest  of  the  wound  with  deep 
and  superficial  sutures.  The  stitches  should  restore  the  integrity  of  the  sphinc- 
ter and  do  away  with  the  presence  of  dead  spaces  in  the  depth  of  the  extensive 
wound.  If  it  is  impossible  to  avoid  the  presence  of  dead  spaces,  such  must 
be  drained. 

If,  in  order  freely  to  excise  the  tumor  it  is  necessary  to  open  the  peritoneum, 


394 


THE    RECTUM. 


do  SO,  but  before  penetrating  that  cavity  carefully  wash  the  wound  with  an 
antiseptic  solution  and  close  the  peritoneal  wound  with  sutures  at  as  early  a 
stage  in  the  operation  as  possible. 

IV.  Sacral  Route. — Every  method  by  which  the  rectum  is  removed  via  the 
sacral  route  is  based  upon  the  Kraske  operation. 

Kraske^s  Operation. — Place  the  patient  on  his  right  side  with  the  thighs 
slightly  flexed. 

Step  I. — Make  an  incision  in  the  middle  line  from  the  middle  of  the  sacrum 
to  the  anal  margin.  This  cut  penetrates  to  the  bone  but  does  not  cut  through 
the  anal  sphincter. 


Fig.  500. 
A,  B,  C.  Kraske's  line  of  section.     H,  K.  Heineke  and  Kocher's  line  of  section. 


Step  2. — Detach  the  gluteus  maximus  on  the  left  side  from  its  sacral  and 
coccygeal  origins. 

Step  3. — Excise  the  coccyx. 

Step  4. — Close  to  the  sacrum,  cut  through  the  lower  part  of  the  left  sacro- 
sciatic  ligament. 

Step  5. — With  chisel  or  strong  bone  forceps  excise  the  left  half  of  that  part 
of  the  sacrum  lying  below  the  level  of  the  third  posterior  sacral  foramen* 
(A,  B,  C,Fig,  500). 

*  Step  5  of  Kraske's  operation  is  frequently  modified.  It  is  found  that  much  more  of  the 
sacrum  may  be  removed,  when  necessary,  than  has  been  described  above.  The  left  half  of 
the  sacrum  up  to  the  second  foramen  has  been  excised,  the  spinal  canal  opened,  and  thejower 
fibres  of  the  cauda  equina  removed  without  evil  resulting. 


KRASKE  S    OPERATION.  395 

Step  6. — Expose  the  rectum  by  dividing  the  soft  structures  lying  between 
it  and  the  sacrum.     Do  not  open  the  gut. 

Step  7. — Separate  the  gut  from  its  surrounding  by  blunt  dissection.  The 
rectal  mesentery  having  been  loosened  (bluntly),  pull  the  gut  downwards  to 
such  an  extent  that  after  the  diseased  section  has  been  freely  removed  the  con- 
tinuity of  rectum  may  be  restored  by  sutures  on  which  no  unnecessary  tension 
may  be  exerted.  It  is  important  not  to  have  opened  the  gut,  as  in  this  step  of 
the  operation  the  peritoneum  is  frequently  opened  either  by  accident  or  design. 
If  the  gut  is  not  opened  and  the  tumor  not  invaded,  the  peritoneum  must  be 
closed  by  sutures  or  packing  (preferably  by  sutures)  after  the  rectum  has 
been  pulled  downwards  to  the  desired  extent.  If  the  peritoneal  wound  has 
become  soiled,  owing  to  escape  of  intestinal  contents  from  an  accidental  tear 
in  the  gut,  it  must  be  cleansed  and  drained  with  iodoform  gauze. 

Step  8. — At  a  point  about  one  and  one-quarter  inches  above  the  disease 
(if  it  is  malignant;  closer,  if  non-malignant)  divide  the  gut  transversely  and 
remove  it  to  a  point  the  same  distance  below  the  disease.  Suture  the  upper 
segment  of  gut  to  the  lower. 

Step  9. — Cleanse  the  whole  wound  carefully.  Diminish  the  size  of  the 
wound  by  a  few  stitches  so  applied  as  to  avoid  interfering  with  the  freest  pos- 
sible drainage.  Pack  the  rest  of  the  wound  loosely  with  iodoform  gauze. 
The  wound  closes  by  granulation.  A  faecal  fistula  frequently  results,  as  the 
intestinal  sutures,  especially  the  posterior  ones,  commonly  give  way. 

Kraske  ('' German  Surg.  Congress,"  1906)  thinks  that  laparotomy  ought 
always  to  be  practised  as  an  immediate  preliminary  to  the  sacral  operation  in 
cases  of  extensive  disease  in  order  to  permit  removal  of  lymphatic  nodes. 
He  divides  the  gut  with  the  cautery  between  two  ligatures  and  thus  renders 
the  lower  segment  mobile  and  easy  of  excision  through  the  sacral  route. 

ReJin's  Modification  of  Kraske's  Operation. — Instead  of  Kraske's  median 
incision  make  a  cut  along  the  left  side  of  the  sacrum  and  coccyx  and  con- 
tinue it  towards  the  anus  (A  B,  Fig.  501).  If  sufficient  space  is  obtained  by 
this  incision,  proceed  with  the  other  steps  of  the  operation.  If  more  room  is 
required,  make  a  transverse  incision  (B  C,  Fig.  501)  over  the  sacrum  between 
the  third  and  fourth  sacral  foramina.  Separate  the  sacrum  from  the  soft 
parts  in  front  of  it  and  divide  the  bone  along  the  line  of  the  transverse  in- 
cision. Reflect  the  newly  formed  flap,  consisting  of  sacrum,  coccyx,  and  soft 
structures  covering  them,  to  the  right. 

The  rest  of  the  operation  is  practically  identical  with  Kraske's,  except 
that  after  the  rectum  is  loosened  from  its  connections  and  pulled  down  so  far 
that  the  suture  of  the  divided  ends  (without  tension)  will  be  possible  after  the 
tumor  is  removed,  the  whole  wound  is  loosely  packed  with  iodoform  gauze 
and  the  rectum  left  unopened  and  not  relieved  of  the  tumor.  During  the  after- 
treatment  the  patient  must  lie  on  his  side.  Keep  the  bowels  locked  up  for 
five  days  with  opium.  On  the  fifth  day  move  the  bowels  with  castor  oil  and 
enemata.     After  the  lapse  of  about  ten  days  from  the  primary  operation,  excise 


396 


THE   RECTUM. 


the  tumor  and  suture  the  ends  of  the  gut  together.  In  doing  so,  first  stitch 
the  mucosa  with  catgut  and  then  unite  the  other  coats  with  silk.  It  strengthens 
the  line  of  sutures  if  the  silk  stitches  include  in  their  bite  some  of  the  neigh- 
boring soft  parts. 

It  is  claimed  that,  among  other  advantages,  the  operation  in  two  stages 
lessens  the  immediate  mortality  of  a  very  serious  procedure — (a)  because 
the  shock  is  lessened,  {b)  because  the  huge  wound  cavity  is  well  covered  by 
granulations  before  there  is  much  chance  of  its  becoming  soiled  by  intestinal 
contents. 

A  distinct  disadvantage  of  Kraske's  operation  is  that  the  levator  and  the 
sphincter  ani  muscles  lose  the  support  which  they  normally  obtain  from  the 


Fig.  501. 


sacrum  and  coccyx.  This  is  important  for  the  future  comfort  of  the  patient. 
In  order  to  save  the  sacrum  and  coccyx  Heineke  and  Kocher  (Fig.  500)  have 
divided  the  coccyx  and  lower  end  of  the  sacrum  longitudinally  in  the  middle 
line  and  retracted  the  fragments  to  either  side,  replacing  them  when  the  opera- 
tion was  completed.  Schlange  has  attained  the  same  object  by  a  method 
which  affords  much  room  and  has  given  excellent  results  in  his  hands. 

Schlange' s  Operation. — Step  1. — Make  a  transverse  incision  down  to  the 
bone  across  the  lower  part  of  the  sacrum. 

Step  2. — From  the  above  incision  make  two  others  (one  on  each  side  of  the 
coccyx)  which  diverge  from  each  other  slightly  and  end  near  the  level  of  the 
anus.     Near  the  anus  these  two  cuts  merely  penetrate  the  skin,  but  where  they 


EXCISION    OF    RECTUM. 


397 


skirt  the  coccyx  and  lower  end  of  the  sacrum  they  divide  the  muscles  and 
ligaments  inserted  into  these  bones. 

Step  3. — With  a  Gigli  wire  saw  divide  the  sacrum  transversely  along  the 
line  of  the  original  skin-incision  (Step  i).  Reflect  downwards  the  flap  of 
bone  and  superjacent  soft  parts  formed  by  the  preceding  steps  (Fig.  502). 
The  rectum  is  isolated,  tumor  excised,  and  intestinal  wound  closed  as  in 
Kraske's  operation.  After  attending  to  hemostasis  the  wound  is  loosely 
packed  with  iodoform  gauze  and  the  sacro-coccygeal  bone-flap  is  partially 
replaced.  The  patient  is  kept  on  his  side  for  a  few  weeks  to  avoid  injury  to 
the  flap;  the  wound  heals  by  granulation  and  the  flap  gradually  assumes  its 
normal  position.     Schlange  was  able  to  exhibit  to  the  Berlin  Medical  Society 


^^^^ 

_^^ 

'  -^  jH 

_  j^'^'j^^^^^M 

'ml 

'\ 

iT^j  : 

Fig.  502. 


a  patient  on  whom  he  had  performed  the  above  operation  six  weeks  previously 
with  a  result  perfect  as  regards  both  comfort  and  function. 

Kiimmel  no  longer  (1906)  excises  much  bone,  nor  does  he  use  large  bone- 
flaps.  He  excises  no  more  than  the  coccyx.  Rotter  does  the  same,  but  leaves 
the  point  of  the  coccyx  with  its  muscular  attachments.  After  dissecting  free 
the  diseased  segment  of  gut  Rotter,  if  possible,  resects  this  segment  and  re- 
establishes the  intestinal  continuity.  If  resection  is  impossible  he  amputates 
the  diseased  and  distal  portions  of  the  gut,  and  pulling  the  upper  segment  of 
gut  through  a  tunnel  bored  through  the  glutei  muscles,  establishes  a  gluteal 
anus  away  from  the  large  coccygeal  wound.  This  little  modification  (estab- 
lishment of  gluteal  anus)  has  been  very  life-saving. 

Rotter's   death   rate  has  fallen  from  32   per  cent,   before   1903   to  43/4 


398  THE   RECTUM. 

per  cent,  since  that  date.  His  late  results  have  been  very  encouraging. 
(See  " Centralblatt  fiir  Chir.,"  July  14,  1906,  or  "La  Presse  Medicale," 
July  21,  1906.) 

W.  J.  Mayors  Modification  of  Kraske's  Operation. — Place  the  patient  in 
the  Trendelenburg  position,  but  on  his  face  instead  of  on  his  back.  The  pel- 
vis must  be  supported  at  the  end  of  the  table  and  the  hips  more  or  less  flexed. 
The  posture  might  he  called  the  reversed  lithotomy  position. 

Step  I. — Make  a  median  incision  from  near  the  anus  up  to  a  point  between 
the  middle  and  base  of  the  sacrum.  Reflect  the  soft  parts  from  the  coccyx 
and  the  lower  half  of  the  sacrum.  Divide  the  soft  parts  attached  to  the  sides 
of  sacrum  and  coccyx  all  the  way  around  these  bones  from  one  sacro-sciatic 
notch  to  the  other. 

Step  2. — With  a  chisel  divide  the  sacrum  transversely  at  the  second  foramen; 
i.  €.,  at  the  level  of  the  sacro-saciatic  notch.  Excise  the  lower  part  of  the 
sacrum  and  the  coccyx.     The  mid-sacral  artery  will  require  ligation. 

Step  3. — Divide  the  levatores  ani  in  the  middle  line.  With  a  pledget  of 
gauze  wipe  downwards  the  external  and  at  least  part  of  the  internal  sphincter 
to  the  anus,  separating  these  structures  from  the  mucosa  of  the  gut.  (It  is 
assumed  that  the  mucosa  here  is  not  involved  in  the  disease) . 

Step  4. — Mobilize  the  rectum  above  the  disease.  Open  the  peritoneum 
and  pack  it  with  gauze.  Pull  the  sigmoid  (pelvic  colon)  downwards,  Ligate 
and  divide  the  inferior  mesenteric  artery.  Open  the  two  folds  of  meso-rec- 
tum  and  wipe  downwards  all  the  fat  and  lymph  tissue  behind  the  rectum  in 
the  cavity  of  the  sacrum.  All  the  diseased  gut  now  lies  loose  except  at  its 
upper  and  lower  ends. 

Step  5. — Pull  the  rectum  upwards  so  that  the  anus  is  pulled  inwards  (or 
upwards).  This  is  possible  because  the  sphincters  have  already  been  sepa- 
rated from  the  anal  mucosa.  Clamp  and  divide  the  gut  at  the  muco-cutaneous 
junction.  The  loosened  sphincters  lie  below  the  clamp.  Clamp  and  divide 
the  gut  well  above  the  disease.     Remove  the  diseased  segment. 

Step  6. — Bring  the  rectal  stump  downwards;  pull  it  through  the  anus 
until  it  protrudes  one  inch.  Fix  it  in  position  with  safety  pins.  If  there  is 
tension  on  the  gut,  incise  the  peritoneum  more  freely  at  the  sides  as  this  is 
the  supporting  force. 

Step  7. — For  a  distance  of  three  inches  upwards  from  the  anus  suture  the 
levatores  ani  muscles  together  and  to  the  posterior  surface  of  the  gut.  (If 
the  internal  sphincter  has  been  divided  and  preserved,  suture  it  along  with 
the  levatores. 

Remove  the  peritoneal  packs.  Attach  the  peritoneum  to  the  gut  with 
interrupted  sutures.  Provide  ample  drainage  by  means  of  split  rubber  tubes 
containing  strips  of  gauze.     Partly  close  the  external  wound. 

After  forty-eight  hours  remove  part  of  the  drains  (all  of  them  if  the  wound 
seems  clean).  FUl  the  wound  with  Van  Arsdale's  fluid  (5  per  cent,  balsam 
of  Peru  in  castor  oil).     Do  not  repack  except  to  keep  the  external  wound  open. 


MUMMERY  S    OPERATION. 


399 


Mummery's  Method  ("Brit.  Med.  Journ.,"  June  i,  1907). — Lithotomy 
position  vdih  pelvis  raised  on  small  hard  cushion.  (Combined  lithotomy  and 
Trendelenburg  postures). 

Step  I. — Wearing  rubber  gloves  dissect  a  cuff  of  mucosa  from  the  anal 
canal  for  about  2  inches,  as  in  the  WTiitehead  operation  for  piles.  With  su- 
tures or  clamp  completely  close  this  tube  of  mucosa  so  that  nothing  can  escape 
from  the  rectum.  With  cautery  or  pure  carbolic  sterilize  the  stump.  Change 
gloves  and  discard  all  instruments  used.     Once  more  cleanse  the  parts. 

Step  2. — Make  a  median  incision  through  the  sphincters  backwards  to  and 
little  beyond  the  base  of  the  coccyx.  Remove  the  coccyx.  Open  the  posterior 
rectal  space  and  separate  from  the  sacrum  by  gauze  dissection  all  the  glands, 
fat,  etc.,  there  present  and  push  these  structures  foru'ard  in  one  piece  along 
vrith  the  rectum. 


Fig.  503. — {Mummery.     ^'Brit.  Med.  Jour") 


Step  3. — Pull  down  the  levator  ani  on  each  side  with  the  finger.  Divide 
the  muscle  close  to  the  rectum.  Separate  the  rectum  from  the  prostate  and 
urethra   (or  from  the  vagina).     This   requires   much  care. 

Step  4. — Open  the  peritoneal  cul-de-sac  and  dixide  the  attachments  of  the 
peritoneum  to  the  rectum  first  on  one  side  and  then  on  the  other,  keeping 
close  to  the  rectum  to  avoid  the  ureters.  This  leaves  the  rectum  free  except 
for  the  meso-rectum. 

Step  5. — Divide  the  meso-rectum  as  near  the  sacrum  as  possible  after 
applying  clamps  or  better  suture  ligatures.  The  rectum  now  comes  down 
freely  and  the  sigmoid  presents.  The  lowest  portion  of  the  sigmoid  is  often 
provided  with  such  a  short  meson  that  it  cannot  be  brought  to  the  anus  with- 
out tension.  Divide  the  meso-sigmoid,  after  appl}'ing  clamps  or  ligatures 
until  a  portion  of  the  gut  is  reached  with  mesentery  long  enough  to  permit 
easy  union  of  gut  to  skin  (see  Fig.  503). 


400 


THE    RECTUM. 


The  tumor  and  all  the  rectum  are  now  outside  the  wound.  Do  not  yet 
divide  the  gut. 

Step  6. — Attend  to  hemostasis  in  a  painstaking  manner.  Suture  the  peri- 
toneum to  the  sides  and  front  of  the  sigmoid.  Close  the  wound  after  provid- 
ing for  "cigarette"  drainage.  Be  specially  careful  to  suture  the  sphincters 
accurately. 

Step  7. — Divide  the  gut  about  3/4  to  i  inch  distal  to  the  sphincter.  Fix 
the  edges  of  the  divided  gut  by  a  few  stitches  not  to  the  margin  of  the  skin- 
wound  but  to  the  skin  itself  about  i  inch  away  from  the  wound.     This  greatly 


Fig.  504.- — [Proust.) 


protects  the  wound  against  fouling.  Later  the  excess  of  mucosa  can  be  cut 
away.  Introduce  a  short  rubber  tube  into  the  bowel  to  permit  passage  of 
gas.     Apply  dressings. 

Proust's  Modification  oj  Kraske's  Operation. — Proust's  account  of  this 
operation  ("La  Presse  Med.,"  December  28,  1907)  is  so  clear  and  so  well 
illustrated  that  it  would  be  unjust  to  that  surgeon  and  to  the  profession  not 
to  give  a  short  description  of  it  here.  For  two  weeks  before  operation  give 
repeated  purgatives  and  enemata.  Give  a  final  purgative  forty-eight  hours 
before  operation.  Give  opium  sufficient  to  thoroughly  constipate  twenty-four 
hours  prior  to  operation. 


Proust's  operation. 


401 


Place  the  patient  on  his  left  side,  thighs  slightly  flexed  and  buttocks  slightly 
over  the  edge  of  the  table.     The  ventral  position  may  be  used. 

Temporarily  close  the  anus  with  a  purse-string  suture. 

Step  I. — Same  as  in  Mayo's  method. 

Step  2. — Divide  the  sacrum  transversely,  four  fingers'  breadth  above  the 
point  of  the  coccyx,  i.  e.,  on  a  line  just  below  the  third  foramen.  Remove 
the  lower  part  of  the  sacrum  and  the  coccyx.  Ligate  the  mid-sacral  artery 
which  lies  on  the  anterior  surface  of  the  bone.  Apply  moist,^hot_pads  to  the 
cut  surface  of  bone  to  stop  bleeding. 


Fig.  505. — {Proust.) 


Step  3. — The  retro-rectal  cavity  with  walls  smooth  as  a  serous  bursa,  is 
now  open.  Carefully  tear  a  hole  in  the  anterior  wall  of  this  cavity,  i.  e.,  in  the 
aponeurotic  sheath,  and  expose  the  posterior  surface  of  the  rectum,  high  up 
on  which  lie  the  superior  hemorrhoidal  vessels.  Ligate  these  (Fig.  504). 
Enlarge  the  opening  in  the  sheath  downwards  to  expose  the  middle  hemor- 
rhoidal vessels.     Ligate  these.     (Fig.  504.) 

Step  4. — Bit  by  bit  separate  the  rectum  from  its  sheath  and  push  it  to  the 

left  until  the  peritoneum  appears  at  the  upper  part  of  the  field.     Open  the 

peritoneum  by  a  vertical  cut  in  the  middle  line.     Introduce  the  finger  and 

hook  it  round  the  gut  so  that  the  point  of  the  finger  raises  the  peritoneum  on 

26 


402 


THE   RECTUM. 


the  opposite  side  of  the  gut.  Open  the  peritoneum  here  also.  Pass  a  loop 
of  gauze  round  the  gut  like  a  scarf  for  purposes  of  traction.  Pack  the  peri- 
toneum with  gauze. 

Step  5. — Pull  the  rectum,  and  with  it  the  sigmoid,  downwards.  Succes- 
sively ligate  and  divide  the  terminal  branches  of  the  inferior  mesenteric  vessels 
in  the  meso-sigmoid  (Fig.  505).  This  dissection  makes  the  descent  of  the 
sigmoid  easy.  Continue  the  dissection  until  the  neoplasm  and  an  ample 
suflSciency  of  healthy  gut  is  delivered  and  until  healthy  gut  above  the  neo- 
plasm can  be  brought  easily  and  without  tension  to  lie  against  healthy  gut 


Fig.  506. — {Proust.) 


below  the  neoplasm.  With  the  gut  bring  away  all  the  suspected  lymphatic 
tissue  of  the  meson. 

Step  6. — Partially  close  with  transverse  sutures  the  vertical  wound  in  the 
peritoneum.  Make  each  suture  pass  through  the  meso-sigmoid  above  the 
part  which  has  been  ligated  and  divided  but  do  not  include  any  vessels  within 
the  sutures.  Tie  the  sutures.  This  partly  closes  the  peritoneum  and  it  fixes 
the  gut  so  that  it  cannot  retract  upwards  (Fig.  506). 

Step  7. — Apply  rubber-covered  intestinal  clamps  to  the  gut  above  and 
below  the  lines  chosen  for  division  of  the  intestine.  Lay  the  clamps  along 
side  each  other  and  unite  the  anterior  surfaces  of  the  two  loops  of  gut  by  a 


Proust's  operation. 


403 


row  of  continuous  Lembert  sutures  on  the  tumor  side  of  the  clamps.  Apply 
crushing  clamps  to  the  two  loops  of  gut  between  the  line  of  Lembert  suture 
and  the  neoplasm.  Divide  the  gut  and  remove  the  neoplasm.  The  crushing 
clamps  prevent  escape  of  contents  from  the  gut  being  removed.  Complete 
the  end-to-end  anastomosis  of  the  gut  (circular  enterorrhaphy)  (Fig.  507). 
The  anterior  and  part  of  the  lateral  surfaces  of  the  gut  are  usually  covered  by 
peritoneum  if  the  tumor  is  fairly  highly  placed  and  hence  good  serous  apposi- 
tion can  be  attained.  The  posterior  surface  is  devoid  of  serosa  and  hence 
union  is  less  accurate.     Proust  therefore  recommends  that  no  attempt  be  made 


Fig.   507. —  {Proust.) 


to  cover  this  portion  of  the  intestinal  wound  by  gliding  flaps  of  parietal  peri- 
toneum over  it,  but  that  the  parietal  peritoneum  should  be  stitched  to  the  gut 
in  such  fashion  as  to  close  the  peritoneal  cavity  and  leave  the  doubtful  portion 
of  the  intestinal  wound  entirely  extraperitoneal.  If  the  tumor  is  found  at 
too  low  a  level  to  permit  of  safe  end-to-end  anastomosis  the  operation  may  be 
finished  by  Mayo's  method. 

Step  8. — Bring  the  edges  of  the  skin  wound  together  with  stitches  deep 
enough  to  catch  up  the  subjacent  tissues.  Drain  all  dead  spaces  with  loose 
gauze  packing.  Remove  the  purse-string  suture  which  closed  the  anus  tem- 
porarily.    Apply  dressings.     Keep  the  patient  constipated  during  one  week. 


404  THE   RECTUM. 

Inguinal  Colotomy  as  a  Preliminary  to  Excision  of  the  Rectum. — Should 
inguinal  colotomy  be  performed  as  a  preliminary  to  excision  of  the  rectum? 
Quenu  seems  to  consider  that  such  is  always  advisable;  other  surgeons  seem 
to  consider  that  it  is  always  needless.  Probably  the  truth  lies  between  these 
extremes. 

Mummery  considers  colotomy  unnecessary  if  it  is  possible  to  thoroughly 
empty  the  bowel  of  all  retained  faeces  before  operation  so  that  one  can  be 
morally  certain  no  fsecal  material  will  find  its  way  into  the  lower  bowel  for 
some  days  after  the  operation  and  the  bowels  can  be  prevented  from  acting 
for  six  or  seven  days.  When  the  above  cannot  be  accomplished  preliminary 
colotomy  is  advisable. 

The  disadvantages  of  a  preliminary  colotomy  are  mainly  the  following: 

(a)  The  annoyance  of  an  operation  performed  some  days  before  the  main 
intervention. 

(b)  The  risk  and  annoyance  of  an  operation  performed  to  close  the  ingui- 
nal anus  some  weeks  after  the  main  intervention. 

(c)  Adhesion  of  the  sigmoid  flexure  to  the  abdominal  wall  at  the  site  of 
the  artificial  anus,  interfering  with  the  pulling  down  of  the  rectum  necessary 
to  excise  the  tumor  and  approximate  the  divided  ends  of  the  gut. 

This  is  the  real  objection  to  the  operation,  but  it  may  be  overcome  either 
by  exercising  care  in  choosing  the  part  of  the  colon  to  be  united  to  the  abdom- 
inal wall  or  by  making  the  artificial  anus  on  the  right  side  of  the  abdomen. 

The  main  advantages  of  preliminary  colotomy  are  as  follows: 

(a)  Through  the  abdominal  cavity  one  can  explore  the  upper  limits  of  an 
extensive  cancer  and  observe  the  presence  of  serious  lymphatic  extension. 

(b)  One  prevents  the  passage  of  faeces  into  the  diseased  rectum  and  can 
thoroughly  irrigate  it  with  solutions  introduced  either  through  the  anus  or 
through  the  colotomy  wound.  During  the  after-treatment  one  is  not  depend- 
ent upon  opium  as  a  means  of  keeping  the  wound  free  from  faecal  contami- 
nation. With  the  aid  of  a  preliminary  colotomy  is  is  easy  at  least  to  approxi- 
mate cleanliness  in  an  excision  of  the  rectum. 

What  are  the  indications  for  radical  operation  in  rectal  cancer? 

Whenever  cancer  of  the  rectum  is  diagnosed,  it  should  be  removed  at 
once.  Too  much  should  be  removed  rather  than  too  little.  This  should  be 
the  invariable  rule  except  when  the  patient's  local  or  general  condition  is 
such  that  the  operation  affords  no  hope  of  recovery,  in  which  case  palliative 
treatment,  e.  g.,  by  colotomy,  must  be  initiated. 

From  careful  examination  of  a  rectum  excised  for  cancer  Sampson  Hardley 
comes  to  certain  conclusions  which  may  be  epitomized  as  follows  ("Brit. 
Med.  Journ.,"  April  i6,  1910): 

(i)  That  permeation  of  the  growth  may  extend  very  widely  in  the  mucous 
plexus  upwards  and  downwards,  reaching  in  a  comparatively  early  stage  of 
the  disease  a  point  at  least  5  inches  from  the  edge  of  the  primary  disease.  The 
affected  section  of  the  bowel  may  appear  quite  healthy  to  ordinary  macro- 


CHOICE    OF    OPERATION.  405 

and  microscopic  examination  (mucicarmine  is  a  specific  stain  for  cancer 
cells  undergoing  mucoid  degeneration)  because  the  permeating  cells  have 
imdergone  myxomatous  degeneration. 

(6)  Permeation  of  the  mucous  lymphatic  plexus  as  a  factor  in  dissemination 
is  probably  limited  in  effectiveness  by  the  habitual  degeneration  of  the  cancer 
cells  in  this  situation. 

(( )  Cancerous  infiltration  in  the  muscular  and  peritoneal  coats  does  not 
extend  far  from  the  primary  growth. 

(i)  Elective  dissemination  probably  occurs  as  a  rule  through  the  meso-rec- 
tum  or  peri-rectal  tissue  opposite  the  primary  growth  and  hence  this  tissue 
must  be  removed. 

(e)  Because  of  the  permeation  referred  to  in  (a)  a  great  length  of  bowel 
should  be  removed  including  the  sphincters. 

A  few  years  ago  cancer  of  the  rectum  was  considered  beyond  remedy  by 
operation  if  the  upper  limits  of  the  tumor  could  not  be  reached  by  the  finger 
passed  through  the  anus.  Mere  extent  of  tumor  along  the  gut  no  longer 
contraindicates  operation.  Extension  of  the  tumor  through  the  intestinal 
walls  and  involvement  of  neighboring  tissues  is  a  matter  of  great  import.  As 
a  general  rule,  it  may  be  said  that  when  the  tumor  has  become  absolutely 
immobile,  the  disease  is  so  widespread  that  operation  is  worse  than  useless; 
that  when  the  immobility  is  only  partial  it  may  possibly  be  due  to  simple  in- 
flammatory adhesions,  and  operations  may  be  justifiable,  though  exceedingly 
dangerous.  Esmarch  does  not  consider  involvement  of  the  base  of  the  bladder 
in  the  cancerous  process  a  contraindication  to  operation — he  boldly  excises 
the  diseased  bladder-wall  and  sutures  the  defect.  Extensive  involvement 
of  the  pelvic  lymphatic  glands  is  a  contraindication  to  operation  which  can 
rarely  be  utilized  unless  the  abdomen  is  explored.  If  one  practises  preliminary 
colotomy,  one  has  the  opportunity  to  examine  the  pelvis  before  fixing  the  colon 
to  the  belly-wall. 

Choice  of  Operation. — In  most  cases  where  the  tumor  is  well  within  the  reach 
and  its  uppermost  extension  can  be  easily  palpated  by  the  finger  introduced 
through  the  anus,  the  operation  through  the  anus  or  perineum  may  be  chosen. 
In  such  localized  and  easily  surmounted  tumors  the  results  are  excellent. 

Kelsey  writes:  "The  advantages  of  the  sacral  incision  may  be  briefly 
enumerated  as  follows: 

"i.  To  dissect  methodically  cancers  situated  high  up,  and  preserve  the 
sphincters. 

"2.  To  completely  remove  cancers  distinctly  circumscribed,  but  which 
would  be  inoperable  by  the  older  methods,  their  upper  limit  being  beyond 
the  reach  of  the  knife. 

"3.  To  preserve,  in  whole  or  in  part,  the  external  sphincter,  even  when 
the  rectum  is  involved  low  down. 

"4.  To  avoid  the  formation  of  a  cloaca,  even  when  the  rectovaginal  septum 
is  invaded  by  the  disease. 


4o6 


THE    RECTUM. 


"5.  To  attack  recurrent  growths  while  yet  limited,  and  give  to  the  sufferers 
one  more  chance  of  health. 

"6.  Finally,  to  render  more  easy  and  precise  the  extirpation  of  non-malig- 
nant strictures." 

Combined  Abdominal  and  Perineal  Rectectomy.- — Quenu's  Method. — 
Step  I. — Place  the  patient  in  Trendelenburg's  position.  Open  the  abdomen 
in  the  middle  line  below  the  umbilicus. 

Step  2. — Ligature  of  both  internal  iliac  arteries.  (This  is  for  the  control 
of  the  middle  and  inferior  hemorrhoidals.)  Note  the  inferior  border  of  the 
promontory  of  the  sacrum;  on  each  side  of  this  can  be  felt  the  pulsation  of 
the  internal  iliac  arteries  or  of  the  common  iliac  if  the  division  has  not  yet 
taken  place.     At  this  level,  i  1/4  inches  (3  cm.)  from  the  middle  line  and  a 


Fig.   508.- — -{Monod  and  Vmiverts.) 


trifle  to  the  inner  side  of  the  pulsating  artery,  place  the  middle  of  a  2 -inch 
incision  through  the  peritoneum  alone.  By  blunt  dissection  retract  the 
outer  lip  of  the  peritoneal  wound  and  with  it  the  ureter.  Expose  the  common 
and  the  external  iliac  arteries.  A  little  downwards  and  inwards  expose  the 
internal  iliac  and  ligate  it  at  a  point  a  little  more  than  1/2  inch  below  the  bifur- 
cation (Fig.  508).  On  the  left  side  the  ligation  is  not  so  easy  as  on  the  right, 
because  the  origin  of  the  meso-sigmoid  hides  the  vessels.  Two  methods  are 
possible:  (a)  Preferable  when  the  meso-sigmoid  is  short.  Lay  the  sigmoid 
flexure  against  the  iliac  fossa;  make  an  incision,  symmetrical  to  that  on  the 
right  side,  so  as  to  get  through  the  meson  and  expose  the  parietal  peritoneum. 
Incise  the  exposed  peritoneum,  retract  the  outer  lip  of  the  peritoneal  wound, 
and  proceed  to  the  ligation  as  on  the  right  side,  {b)  If  the  meso-sigmoid  is 
very  long,  pull  the  sigmoid  upwards,  incise  the  parietal  peritoneum  immediately 
below  the  origin  of  the  meson,  and  thus  reach  the  vessels  directly.     When 


QUENU'S    OPERATION. 


407 


it  is  evident  that  the  ligation  of  the  left  internal  iliac  will  be  diflScult,  it  is  sim- 
pler to  put  this  step  off  until  after  the  sigmoid  has  been  divided  and  the  field 
of  operation  has  been  made  easier  of  access.  While  the  iliac  vessels  are  ex- 
posed, examine  this  region  for  enlarged  lymphatic  glands.  Close  the  wounds 
made  in  the  peritoneum  over  the  arteries. 

Step  3. — At  a  point  free  from  blood-vessels  tear  a  hole  in  the  meso-sigmoid 
and  pass  a  large  strip  of  gauze  through  it  (Fig.  509).  Protect  the  abdominal 
cavit>'  vdth  gauze  pads.  With  the  fingers  empty  the  contents  from  that  portion 
of  the  sigmoid  opposite  the  tear  in  the  meson.  Doubly  ligate  the  gut  and 
divide  it  between  the  ligatures,  preferably  with  the  thermocautery.  Cover 
the  divided  ends  of  gut  with  gauze  and  rubber  caps  held  in  place  by  a  thread 
or  a  rubber  band.     This  to  prevent  soiling.     Working  downwards  from  the 


Fig.  509. — (Monod  and  Vanverts.) 


tear  in  the  meso-sigmoid,  divide  that  structure  between  forceps  or  ligatures 
and  push  aside  temporarily  the  lower  segment  of  gut  (Fig.  510).  (Sudeck, 
"Muench.  med.  Woch.,"  July  2,  1907)  gives  a  very  clear  idea  of  the  inferior 
mesenteric  artery.  It  is  best,  if  possible,  to  ligate  the  artery  after  it  gives  off 
its  last  important  anastomotic  branch,  i.  e.,  when  the  ligation  is  for  hemo- 
stasis  and  not  for  mobilization. 

Step  4. — Make  an  incision  in  the  left  iliac  region  through  the  parietes  (Fig. 
511)  and  pull  the  divided  end  of  the  upper  segment  of  gut  through  this.*  Fix 
the  gut  in  position  by  a  few  sutures.  A  permanent  artificial  anus  is  thus 
provided. 

Step  5. — Pull  the  lower  segment  of  gut  (viz.,  that  to  be  removed)  forwards 
and   upwards    against    the   pubis.     Divide   the  meso-rectum  and  ligate  the 

*  This  incision  is  best  made  in  exactly  the  same  way  as  in  McBurney's  muscle-splitting 
operation  of  appendectomy. 


408  THE    RECTUM. 

hemorrhoidal  vessels.  When  the  posterior  connections  of  the  rectum  have 
been  separated,  proceed  to  incise  the  recto-vesical  cul-de-sac  if  this  is  possible 
of  access.  Lay  the  whole  lower  segment  of  gut,  well  covered  with  guaze  pads, 
in  the  deepest  part  of  the  pelvic  fossa.  Completely  close  the  abdominal  wound, 
after  as  far  as  possible  diminishing  the  peritoneal  laceration  by  means  of  sutures 
applied  to  the  remnants  of  the  meso-rectum. 

Step  6. — Place  the  patient  in  the  lithotomy  position  and  complete  the  opera- 
tion by  removing  the  loosened  rectum  and  its  protecting  pads  of  gauze  by  the 
perineal  route,  if  necessary  excising  the  coccyx  and  portions  of  the  sacrum. 
Provide  for  perineal  drainage  and  close  the  perineal  wound  with  sutures. 


Fig.  510. — (Sudeck.) 

Step  7. — According  to  circumstances,  either  leave  the  portion  of  gut  which 
has  been  fixed  in  the  left  iliac  region  untouched  for  two  or  three  days  or  open 
it  immediately  so  as  to  empty  the  bowels.  In  the  formation  of  the  artificial 
anus  the  use  of  Paul's  tube  will  aid  in  preventing  soiling  of  the  dressings.* 

Modified  Quenu  Operation. — Slcp  i. — Place  the  patient  in  the  high  Tren- 
delenburg position.  Open  the  abdomen  in  the  middle  line  below  the  umbili- 
cus. Examine  as  to  the  possibility  of  removing  the  disease.  Protect  all  the 
intestines  with  gauze  pads,  leaving  the  sigmoid  and  rectum  free. 

Step  2. — Apply  two  clamps  to  the  gut  well  above  the  disease  and  divide  the 

*  The  above  description  has  been  taken,  practically  completely,  from  Monod  and  Van- 
verts'  "Traite  de  Technique  Operaloire." 


weir's  operation. 


409 


gut  between  them.  Close  each  end  of  gut  by  a  row  of  through-and-through 
sutures.  Invaginate  the  stumps  into  the  lumen  of  the  gut  by  a  purse-string 
suture  as  in  appendectomy.  Leave  uncut  the  suture  attached  to  the  upper 
segment  of  gut;  apply  a  hemostat  to  the  end  of  the  suture;  the  suture  will  act 
as  a  guide  to  the  gut  later. 

Step  3. — Pull  the  end  of  the  lower  segment  of  gut  up  into  the  wound.  On 
each  side  of  the  gut  make  a  cut  through  the  peritoneum  of  the  meson  parallel 
to  the  gut  and  strip  back  the  peritoneum.  If  the  lower  part  of  the  sigmoid 
forms  a  part  of  the  lower  or  rectal  segment  of  gut,  ligate  its  vessels  which  are 
easily  seen.  Continue  the  incisions  in  the 
meson  downwards  on  each  side  of  the 
rectum,  stripping  the  peritoneum  off  the 
meso-rectum.  Divide  the  peritoneum  an- 
teriorly so  as  to  separate  the  rectum  from  the 
uterus,  or  from  the  bladder,  prostate,  etc. 

Step  4. — Find  and  ligate  the  inferior 
mesenteric  artery  just  to  the  left  of  the 
promontory  of  the  sacrum.  With  gauze 
wipe  downwards  all  the  fat  and  lymphatic 
tissue  posterior  to  the  rectum;  this  is  ren- 
dered possible  by  the  incision  and  reflection 
of  the  peritoneal  surfaces  of  the  meson. 
While  wiping  the  fat  downwards  expose 
and  ligate  the  middle  sacral  artery  as  high 
as  possible.  Continue  the  gauze  dissection, 
laying  bare  the  internal  iliac  vessels  and  the 
ureters.  Find  and  ligate  the  middle  hemor- 
rhoidal" arteries  which   arise,  one  on  each 

side,  from  the  anterior  divisions  of  the  internal  iliac  arteries  and  run  inward 
to  the  middle  portion  of  the  rectum. 

Step  5. — If  sufi&cient  gut  above  the  anus  is  healthy,  complete  the  operation 
by  Weir's  method.  If  restoration  of  the  continuity  of  the  intestinal  canal 
is  impossible  or  too  dangerous,  complete  as  in  Quenu's  operation. 

R.  F.  Weir's  Operation. — This  operation  is  suitable  in  cases  of  cancer 
situated  high  up  in  the  rectum. 

Step  I. — Open  the  abdomen  in  the  middle  line  or  through  the  left  rectus 
muscle. 

Step  2. — Free  the  rectum  from  its  connections  to  a  point  near  the  tip  of  the 
coccyx  posteriorly  and  to  the  edge  of  the  prostate  anteriorly. 

Step  3. — Divide  the  gut  between  two  ligatures  above  the  tumor  (Fig.  512). 

Step  4. — By  means  of  forceps  passed  up  through  the  anus  seize  the  upper 
end  to  the  lower  segment  of  gut  and  pull  it  out  through  the  anus,  thus  inverting 
the  gut.     Cut  away  the  tumor. 

Step  5. — Pull  the  distal  end  of  the  proximal  segment  through  the  inverted 


Fig.  511. — {Monod  and  Vanverts.) 


4IO 


THE   RECTUM. 


lower  segment.  The  serous  surfaces  of  the  two  segments  lie  in  apposition. 
Unite  the  two  segments  by  means  of  Maunsell's  method  of  sutunng  (Figs. 
513  and  514)- 


YiG,  ^12.— (Weir,  "Jour.  Am.  Med.  Assoc") 


Fig.  514- 
Figs.  7^2^]%  and  s^.-iWeir,  "Jour.  Am.  Med.  Assoc") 

Step  6 -Reduce  the  prolapsed  gut.  Suture  the  pelvic  peritoneum  divided 
when  freeing  the  rectum  from  its  connections  (Fig.  5x5).  This  -ture  shuts 
Iff  the  general  peritoneal  cavity  from  the  deep  portion  of  the  pelvis.     Dram 


TUTTLE  S    OPERATION. 


411 


the  lower  portion  of  the  pelvis  through  an  incision  made  behind  the  anus 

(Fig.  515)- 

Maunsell  and  Trendelenburg  have  performed  a  very  similar  operation, 
but  drain  the  deep  pelvis  with  gauze  brought  out  through  the  abdominal 
wound. 

TuUle's  Operation. — ("Amer.  Journ.  Surg.,"  June,  1910.)  Prepare  the 
patient  during  several  days  by  diet,  purges,  irrigations,  etc.  Immediately 
before  operation  irrigate  the  rectum  vsdth  a  3  per  cent,  solution  of  formalin, 
wiping  this  out  and  then  injecting  two  or  three  ounces  of  pure  peroxide  of 
hydrogen  up  into  the  rectum  and  above  the  tumor  if  possible. 


Fig.  515. — {Weir,  "Jour.  Am.  Med.  Assoc") 


Step  I. — Put  the  patient  in  the  Trendelenburg  position.  Freely  open  the 
abdomen  by  a  longitudinal  incision  just  outside  the  left  rectus  muscle.  Ex- 
amine for    adhesions,  metastasis,  etc. 

Step  2. — Treatment  of  meso-sigmoid.  Select  "a  point  on  the  sigmoid 
two  inches  further  above  the  tumor  than  the  latter  is  above  the  anus."  Make 
a  small  incision  in  the  peritoneal  layer  of  the  meso-sigmoid,  one-half  inch 
from  the  margin  of  the  gut;  introduce  through  the  incision  a  thin  spatula-like 
director  and  on  this  as  a  guide  incise  the  peritoneum  parallel  with  the  gut 
down  to  the  tumor.  Turn  the  gut  over  and  repeat  the  process  on  the  other 
side  of  the  meso-sigmoid.  Strip  the  peritoneum  back  on  both  sides  of  the 
meson  to  its  origin  on  the  posterior  abdominal  wall.    Division  of  the  peritoneum 


412 


THE   RECTUM. 


as  described  permits  the  gut  to  be  pulled  further  out  of  the  wound  and  facili- 
tates tying  the  blood-vessels  and  removing  the  glands. 

Step  3. — The  gut  being  pulled  upwards  through  the  wound,  begin  near 
the  origin  of  the  visible  vessels  to  brush  all  fat  and  glands  from  them  by  gauze 
dissection,  towards  the  intestine  until  the  lower  sigmoidal  artery  is  found  and 
traced  to  its  origin  in  the  superior  hemorrhoidal.  Doubly  tie  and  divide  the 
superior  hemorrhoidal  artery  just  above  the  origin  of  the  lower  sigmoidal, 
which  point  is  usually  just  below  the  promontory  of  the  sacrum  and  in  the 
angle  of  the  iliac  vessels. 

A  glance  at  Fig.  516  shows  that  if  the  ligation  is  made  as  directed  (XX') 
the  anastomosis  between  the  colonic  and  hemorrhoidal  vessels  is  ample  to 

keep  up  the  circulation  in  the  latter. 
An  extra  amount  of  mobilization  may 
be  obtained  by  double  ligation  and 
division  of  another  anastomotic  trunk 
at  YY'  without  interference  with  the 
rectal  nutrition. 

Step  4. — Split  the  deep  fascia  be- 
hind the  lower  stump  of  the  ligated 
vessels  and  peel  the  rectum,  fat  and 
glands  out  of  the  sacral  cavity  down  to 
the  tip  of  the  coccyx  posteriorly  and  to 
the  upper  surface  of  the  levatores  ani 
on  the  sides.  Pack  the  cavity  with  hot 
moist  gauze  to  control  oozing. 

Step  5. — Carry  the  peritoneal  inci- 
sion "across  the  gut  one  inch  above  the  tumor  and  through  the  cul-de-sac 
between  the  gut  and  the  bladder  or  the  uterus  as  the  case  may  be." 

Separate  the  gut  from  the  anterior  organs  by  blunt  dissection  as  far  down 
as  possible  without  too  great  traumatism,  usually  as  far  as  the  prostate  at 
least. 

Step  6. — Remove  the  gauze  from  the  sacral  cavity.  Examine  the  sigmoid 
and  on  it  choose  the  lowest  portion  (well  above  the  tumor)  where  the  nutrition 
is  above  reproach.  Carry  this  part  of  the  sigmoid  down  to  the  tip  of  the  coccyx 
to  measure  whether  it  can  be  brought  out  of  the  anus  without  tension.  If 
it  cannot,  study  whether  it  is  the  blood-vessels  or  the  peritoneal  covering  of 
the  meso-sigmoid  which  holds  it.  If  the  peritoneum,  then  increase  the  inci- 
sion made  in  Step  2;  if  the  vessels,  feel  which  one  is  at  fault  and  divide  it  be- 
tween two  ligatures  (Fig.  516,  YY')  in  such  a  manner  as  not  to  interfere  with 
anastomosis. 

Step  7. — Method  A. — The  tumor  is  of  moderate  size  and  is  three  inches 
or  more  from  the  anus.  Tie  a  narrow  tape  with  long  ends  around  the  gut 
just  above  the  tumor.  Have  an  assistant  dilate  the  anus  and  pass  through 
it  a  long  dressing  forceps  to  a  point  just  below  the  tumor.     Protect  the  abdo- 


BALFOUR  S    OPERATION.  413 

men  with  pads.  Make  the  points  of  the  forceps  perforate  the  gut  just  below 
the  tumor;  seize  the  ends  of  the  tape  with  the  forceps  and  pull  them  into  the 
gut  and  out  through  the  anus.  By  pulhng  on  the  tapes  and  pushing  the  tumor 
downwards,  the  tumor  is  invaginated  into  the  lower  segment  of  gut  and  out 
through  the  anus  dragging  after  it  the  lower  segment  of  mobilized  sigmoid 
to  the  desired  extent.  Replace  all  reflected  flaps  of  peritoneum  and  repair 
all  peritoneal  wounds  with  sutures  until  the  floor  of  the  pelvis  and  the  meso- 
sigmoid  are  entirely  restored.  Close  the  abdomen.  Put  the  patient  in  the 
lithotomy  position.  Cut  through  the  rectum  or  surrounding  tube  (intussus- 
cipiens)  all  around,  catch  the  edges  with  forceps.  Through  this  circular 
wound  note  the  intussuscepting  sigmoid  (intussusceptum)  and  find  the  lowest 
point  in  it  where  the  circulation  is  good  (prove  that  the  circulation  is  good 
by  puncturing  with  a  needle)  and  yet  which  is  high  enough  above  the  tumor. 
Suture  this  portion  of  sigmoid  to  the  wall  of  the  everted  rectum.  Cut  away 
the  gut  below  the  line  of  suture  and  stitch  the  mucous  membrane  of  the  sig- 
moid to  that  of  the  rectum.  Pass  a  large  rubber  tube  into  the  rectum.  With 
four  sutures  passed  through  the  margin  of  the  gut  and  the  skin  outside  the 
anus  prevent  retraction  inwards  of  the  line  of  suture  until  union  has  taken 
place.  Mayo  uses  safety  pins  instead  of  sutures.  Drainage  is  secured  by  a 
tube  or  cigarette  drain  introduced  into  the  hollow  of  the  sacrum  through 
a  cut  made  alongside  the  coccyx. 

Method  B. — -The  tumor  is  high  up  and  too  large  to  be  evaginated  through 
the  anus.  Have  the  assistant  make  an  incision  alongside  the  coccyx  and 
through  this  pull  out  the  tapes  and  with  them  the  sigmoid.  Repair  the  peri- 
toneum and  close  the  abdomen.  Excise  the  tumor  through  the  parasacral 
incision,  enlarging  this  if  necessary.  Unite  the  ends  of  the  gut  by  circular 
suture  or  evaginate  them  through  the  anus  and  treat  them  after  the  manner 
described  in  Weir's  operation,  p.   409. 

Method  C.  Balfour's  Method. — ("Annals  of  Surg.,"  Feb.,  1910.)  Suitable 
for  tumors  near  the  junction  of  the  rectum  and  sigmoid. 

Step  I. — Place  the  patient  in  the  high  Trendelenburg  position.  Excise 
the  tumor  in  the  usual  manner,  through  an  abdominal  incision. 

Step  2. — Provide  a  rubber  tube  about  3/4  inch  in  diameter  similar  in  stiff- 
ness to  those  used  for  colonic  lavage.  The  tube  should  have  a  lateral  eye 
near  its  end  to  permit  the  escape  of  gas  should  the  end  become  obstructed. 
Pass  the  tube  from  the  abdomen  through  the  lower  segment  of  gut  so  as  to 
protrude  through  the  anus.  Pass  the  "eyed"  end  of  the  tube  into  the  proxi- 
mal segment  of  sigmoid  for  about  3  inches  having  previously  prevented  acci- 
dental extrusion  of  faecal  matter  by  the  application  of  a  guarded  clamp  placed 
sufficiently  high  above  the  line  of  section.  One-half  inch  above  the  cut  end 
of  the   sigmoid  fix  the  tube  to  the  intestine  by  a  transverse  stitch  of  catgut 

(Fig.  517)- 

Step  3. — Have  an  assistant  pull  upon  the  tube  projecting  from  the  anus 
until  the  cut  ends  of  the  proximal  and  distal  segments  of  intestine  are  in  ap- 


414 


THE   RECTUM. 


position.  Unite  the  upper  to  the  lower  segment  of  intestine  by  carefully  applied, 
interrupted,  through-and-through  sutures  of  chromicized  catgut.  Be  careful 
to  coapt  the  mucous  membranes  (Fig.  518). 

Step  4. — Have  the  assistant  once  more  pull  upon  the  protruding  tube  so  as  to 
produce  an  invagination  of  the  proximal  for  about  1/2  inch  into  the  distal 
segment  of  gut.  Assist  this  invagination  by  steadying  the  lower  segment  of 
the  intestine  with  a  few  forceps.  Insert  sero-muscular  sutures  around  the 
invagination  to  prevent  the  withdrawal  of  the  intussusceptum  (Fig.  519). 
(Occasionally  it  has  been  impossible  to  insert  the  second  row  of  sutures  and  yet 
good  results  have  been  obtained.) 


W'X 


Fig. 


Fig. 


519- 


Step  5. — Repair  the  peritoneal  wound  behind  the  anastomosis  by  sliding 
the  peritoneum  and  suturing  it.  Pull  the  omentum  down  over  the  site  of 
anastomosis  and,  if  necessary,  secure  it  there  by  a  catgut  suture. 

Step  6. — Close  the  abdomen  after  providing  for  drainage. 

The  rubber  rectal  tube  remians  in  situ  until  the  catgut  suture  is  absorbed 
(about  six  days).  Do  not  remove  the  abdominal  drain  for  one  week  because 
a  temporary  fascal  fistula  sometimes  occurs. 

Rotter  ("Handbuch  der  praktischen  Chirurgie")  writes:  ''The  tendency 
of  the  French  to  make  a  permanent  iliac  anus  in  every  case  is  not  approved 
in  Germany.  Whenever  practicable,  we  endeavor  to  preserve  the  sphincter 
ani,  and  consequently  continence.  This,  as  a  rule,  can  be  attained.  The 
danger  of  infection  is  very  slight,  as  the  gut  is  only  opened  at  the  end  of  the 


EXCISION    OF    RECTUM.  415 

operation.  If  union  of  the  divided  ends  of  the  gut  is  impossible  owing  to  the 
shortness  of  the  upper  segment,  we  prefer  to  make  a  sacral  rather  than  an 
iliac  anus." 

German  surgeons,  as  a  rule,  make  use  of  an  abdomino-dorsal  instead  of 
an  abdomino-perineal  operation.  By  the  sacral  (dorsal)  route  they  expose 
and  free  the  rectum  as  far  as  conditions  permit,  and  then,  if  they  meet  with 
difficulties,  open  the  abdomen,  mobilize  the  gut  to  the  necessary  extent,  close 
the  abdominal  wound,  and  pull  the  gut  (rectum  and,  if  necessary,  sigmoid) 
out  of  the  sacral  wound,  when  the  neoplasm  is  excised  and  the  divided  ends  of 
gut  united  by  circular  enterorrhaphy  or  by  the  invagination  method. 


CHAPTER  XXXV. 
HEMORRHOIDS  AND  FISTULA. 

External  Haemorrhoids. — External  haemorrhoids  are  practically  never 
operated  on  except  when  inflamed.  It  is  well  to  snip  away  with  scissors 
any  tags  of  skin  around  the  anus  at  the  same  time  as  the  pile  is  attacked; 
this  to  avoid  subsequent  trouble. 

Hold  the  inflamed  pile  between  the  finger  and  thumb  of  the  left  hand. 
Transfix  the  base  of  the  pile  with  a  knife  in  the  direction  of  the  radiating  anal 
folds.  Cut  outwards  between  the  finger  and  thumb,  thus  splitting  the  pile. 
By  squeezing  or  with  a  forceps  or  curette  evacuate  the  contained  blood-clot. 
Remove  with  scissors  redundant  tissues.  Sutures  are  unnecessary.  Apply 
a  little  simple  ointment  and  a  pad  of  cotton.  The  after-treatment  consists 
in  keeping  the  bowels  open,  occasional  washing  of  the  parts,  reapplication  of 
ointment  and  pad  and  the  exercise  of  moderate  patience  for  a  few  days. 

Internal  Haemorrhoids. — Preparatory  Treatment. — Evacuate  the  bowels 
thoroughly.  Allingham  advised  giving  two  pills  each  containing  blue  mass 
gr.  j.  with  gr.  v  of  pil.  colocynth.  et  hyoscyomi  thirty-six  hours  before  opera- 
tion and  using  an  enema  of  soap  and  water  a  few  hours  prior  to  operating. 
This  method  is  as  good  as  any. 

Methods  of  Operating. — I.  Excision. — (a)  Place  in  lithotomy  position. 
Dilate  anus  completely  with  thumbs  or  bivalve  speculum.  Catch  each  pUe 
to  be  removed  in  a  forceps.  The  removal  of  three  pile  masses  is  all  that  is 
usually  necessary;  if  more  are  removed  stricture  may  result.  Cut  away  the 
lowermost  pile  with  scissors.  Pick  up  and  ligate  all  bleeding  vessels.  Suture 
the  wound.  The  operation  is  easy  on  paper,  but  it  is  not  easy  to  pick  up  the 
vessels  and  to  apply  the  suture  neatly.  Before  it  was  customary  to  dilate  the 
anus  completely,  excision  was  dangerous  because  of  concealed  haemorrhage 
into  the  rectum.     This  danger  no  longer  exists. 

(6)  Thelwell  Thomas'  method  is  a  type  of  operation  devised  by  many 
surgeons. 

Lithotomy  position:  Completely  dilate  anus.  Catch  the  pile  masses  in 
forceps.  Grasp  the  base  of  one  pile  in  a  forceps  having  a  blade  about  21/2 
inches  long  and  not  too  thick.  Be  careful  not  to  include  any  of  the  skin  in 
the  forceps.  Cut  away  the  pile  about  3/8  inch  distal  to  the  forceps.  Arm  a 
stout  catgut  suture  about  ten  inches  long  with  a  rounded  needle  at  each  end. 
Pass  the  suture  through  the  upper  end  of  the  stump  distal  to  the  clamp  and 
tie  firmly.  Do  not  cut  the  suture,  but  pass  the  needles  one  from  one  side,  the 
other  from  the  other  side  through  the  stump  about  3/8  inch  away  from  the 

416 


HEMORRHOIDS. 


417 


first  stitch  and  tie  firmly  over  the  stump.  Repeat  the  stitch  (Fig.  520)  as 
often  as  necessary  to  completely  suture  the  stump.  Remove  the  clamp. 
There  may  be  a  little  oozing  from  the  mucous  membrane  where  crushed  by 
the  clamp.  Treat  the  other  tumors  in  the  same  may.  It  is  usually  only  neces- 
sary to  remove  three  pile  masses.  If  more  tumors  must  be  removed  and 
stricture  is  feared,  Thomas  advises  to  apply  the  clamp  to  one  or  more  of  the 
tumors  transversely  to  the  axis  of  the  gut  and  suture  in  the  same  direction, 
the  resulting  scar  being  transverse  also. 

After-treatment. — On  completion  of  the  operation  introduce  two  supposi- 
tories, one  containing  3  grs.  of  iodoform,  the  other  1/2 
gr.  of  morphine.     Apply  a  pad  of  gauze  or  cotton  and 
some  simple  ointment  to  the  anus. 

On  the  fifth  day  give  a  laxative.  After  the  bowels 
move  introduce  an  iodoform  suppository.  The  author 
finds  that  there  is  little  use  in  keeping  the  bowels 
locked  up ;  if  they  show  a  tendency  to  move  it  is  satis- 
factory to  give  an  enema  of  a  few  ounces  of  warmed 
sweet  oil.  A  favorite  dressing  with  some  surgeons  is 
to  introduce  into  the  rectum  a  tube  surrounded  by 
gauze:  the  tube  permits  the  exit  of  gas;  the  gauze  is 
supposed  to  keep  the  wound  clean  and  prevent  bleed- 
ing. This  dressing  ought  to  be  reserved  for  personal 
enemies  and  malefactors  as  it  does  no  good  and  can 
cause  much  suffering.  After  excision  the  patient  is 
generally  well  by  about  the  seventh  day. 

II.  Ligation. — (a)  Lithotomy  position:  Dilate  the  anus  completely. 
Catch  the  piles  to  be  removed  with  forceps.  Pull  the  lowermost  pile  down- 
wards by  the  forceps  attached  to  it.  Note  the  white  line  at  the  junction  of 
the  skin  and  mucous  membrane;  beginning  at  this  line  immediately  below  the 
pile,  with  scissors  separate  the  pile  from  the  subjacent  submucous  and  muscu- 
lar tissues  on  which  it  rests.  Continue  the  separation  upwards  until  the  pile 
remains  hanging  by  a  small  pedicle  of  vessels  and  mucous  membrane.  This 
is  possible  and  safe  because  all  the  vessels  enter  or  leave  the  tumor  above, 
immediately  under  the  mucous  membrane.  Tie  the  pedicle  tightly  with  a 
strong  but  not  thick  silk  ligature.  Cut  away  the  tumor  distal  to  the  ligature. 
Before  applying  the  ligature  it  may  be  convenient  to  crush  a  groove  in  the  ped- 
icle with  a  strong  forceps.  This  permits  the  use  of  a  lighter  ligature.  Treat 
the  other  piles  in  the  same  manner. 

(6)  Modified  ligation:  Separate  the  pile  as  for  ligation.  Divide  the  mucous 
membrane  above  the  pedicle  so  that  the  pedicle  comes  to  consist  of  vessels 
alone.  Ligate  the  vessels  with  catgut.  Suture  the  mucosa.  This  operation 
is  practically  an  excision. 

III,  Clamp  and  Cautery  Operation. — Many  clamps  have  been  devised. 
The  simplest  are  Langenbeck's,   Smith's  or  Gant's.     Some  have  ivory  on 

27 


Fig.  520. 


41 8  HEMORRHOIDS. 

the  under  side  to  keep  the  heat  from  burning  the  skin.  A  piece  of  asbestos 
paper  placed  between  the  clamp  and  the  skin  is  a  cheap  and  effective  substi- 
tute for  the  ivory. 

Lithotomy  position:  Dilate  the  anus  completely.  Seize  with  forceps 
each  pile  to  be  removed.  (The  removal  of  three  pile  masses  usually  suffices.) 
Seize  the  base  of  the  lowermost  pile  in  a  clamp.  Arrange  asbestos  paper 
between  the  clamp  and  the  skin.  Burn  away  the  protruding  pile  completely 
with  the  cautery.  Some  surgeons  cut  away  the  pile,  leaving  a  stump  3/4  inch 
long  protruding  from  the  clamp  and  cauterize  this  stump.  Paquelin's  cautery 
is  useful  in  this  operation;  so  is  an  electro-cautery,  but  both  these  instruments 
are  fairly  expensive  and  often  out  of  order.  Ordinary  soldering  irons  are 
cheap,  easily  heated  in  a  lamp  and  are  always  reliable.  They  should  be 
heated  to  a  dull  red  color  and  allowed  to  cool  slightly  before  being  used. 

IV.  Excision  of  the  Pile-hearing  Area. — {a)  Whitehead's  operation,  sometimes 
called  the  American  operation. — Lithotomy  position:  Dilate  anus  completely. 
Make  an  incision  all  around  the  anus  at  the  junction  of  the  skin  and  mucous 
membrane.  Separate  the  mucous  membrane  by  blunt  and  occasional  sharp 
dissection  from  the  external  and  internal  sphincter.  Attend  to  hajmostasis. 
The  whole  pile-bearing  area  (there  are  exceptions  to  this  rule)  now  hangs 
separated  from  the  subjacent  tissues.  Divide  the  mucous  membrane  trans- 
versely above  the  pile  area  in  successive  stages.  As  each  segment  of  mucosa 
is  divided  bring  its  free  margin  down  and  suture  it  to  the  corresponding  edge 
of  skin.  This  is  much  easier  than  cutting  off  the  whole  loosened  segment 
of  gut  at  once. 

(b)  Vercesco's  Method  (Potarca,  "Rev.  de  Chir.,"  May,  1902).— Prepare  a 
champagne  cork  by  providing  its  narrow  end  with  a  handle  (a  loop  of  stout 
wire  is  satisfactory).     Have  a  number  of  fine  tacks  ready. 

Lithotomy  position:  Fully  dilate  anus.  Reduce  the  piles.  Pass  the 
champagne  cork,  thick  end  first,  into  the  bowel.  Make  a  short  incision  through 
the  muco-cutaneous  junction.  Tack  the  separated  mucosa  to  the  cork. 
Repeat  this  until  the  incision  runs  completely  round  the  anus  and  the  whole 
circumference  of  the  mucosa  is  tacked  to  the  cork.  By  means  of  the  handle 
on  the  cork  pull  the  cork  and  with  it  the  gut  downwards  and  separate,  as  in 
Whitehead's  operation,  the  pile  area  from  the  subjacent  structures.  Attend 
to  haemostasis.  Suture  the  free  edge  of  skin  to  the  raw  surface  of  the  mucosa 
(on  the  cork)  all  around  the  anus.  With  a  knife  divide  the  mucous  membrane 
immediately  distal  to  the  line  of  suture  and  remove  the  cork  and  with  it  the 
pile-bearing  tissues.  Instead  of  suturing  as  above  one  may  make  a  short 
incision  through  the  mucosa,  suture  it  to  the  corresponding  free  edge  of  skin 
and  repeat  this  alternate  cutting  and  suturing  until  the  operation  is  completed. 
The  advantage  of  this  method  over  the  Whitehead's  consists  in  the  avoidance 
of  soiling  the  deep  wound  with  intestinal  discharge  during  the  operation. 

Choice  of  Operation. — Excision  of  the  pile-bearing  area  depends  for  success 
on  healing  by  first  intention.     This  does  not  always  take  place;  if  it  does  not 


FISTULA    IN   ANO. 


4iy 


then  healing  must  be  by  granulation  and  stricture  results.  Wetherill  has  seen 
cases  where  after  perfect  union  was  obtained  the  sensitiveness  of  the  anus 
was  so  obtunded  that  the  normal  impulses  which  precede  and  call  for  the  act 
of  defaecation  were  absent  and  a  condition  of  persistent  constipation  was 
established.  The  same  cause  may  lead  to  incontinence  of  gas  and  fcxces. 
The  other  methods  of  operating  all  give  good  results.  Each  surgeon  knows 
that  the  method  he  uses  gives  better  results  than  any  other.  The  author's 
preference  is  for  the  Th  el  well  Thomas  operation. 

Pruritus   Ani. — In  long-standing  cases  of  pruritus  where  medical  treat- 
ment   has    failed    to    give   relief   and 
where  no  evident  removable  cause  for  = 

the  itching  can  be  found,  a  cure  may 
be  affected  by  one  of  two  operations: 

I. — Cauterization. — Administer  a 
general  anaesthetic.  Thoroughly  dilate 
the  anus.  Remove  any  tags  of  skin  or 
small  polypi  which  may  present.  Ap- 
ply lightly  the  flat  side  of  a  Paquelin 
cautery,  at  a  white  heat,  to  every  part 
of  the  affected  anal  skin.  Only  the 
superficial  epithelium  ought  to  be  de- 
stroyed and  on  recovery  there  should 
be  no  scar  formation. 

II.  Balls  Operation. — Division  of 
the  terminal  branches  of  the  nerves 
supplying  the  affected  skin. 

Step  I. — The  patient  being  in  the 
lithotomy  position,  makes  the  incision  A  B  (Fig.  521)  on  one  side  of  the  anus 
and  reflect  the  flap  X,  consisting  of  skin  and  subcutaneous  tissue.  The  fibres 
of  the  external  sphincter  should  be  exposed  and  the  dissection  continued  up 
to  and  beyond  the  muco-cutaneous  junction.  With  scissors  undermine  for  a 
short  distance  the  skin  to  the  outer  side  of  the  incision  A  B. 

Step  2. — On  the  opposite  side  of  the  anus  make  the  incision  C  D  and 
reflect  the  flap  Y  as  in  Step  i.  Be  careful  that  the  distance  between  A  and  C 
and  between  B  and  D  is  fully  one  inch. 

Step  3. — With  scissors,  undermine  the  bridges  of  skin  A  C,  B  D.  Attend 
to  haemostasis. 

Step  4. — Replace  the  flaps  X  and  Y  and  suture  the  wounds  A  B  and  C  D. 
Apply  dressings.     Sensation  gradually  returns  in  the  area  of  operation. 

FISTULA  IN  ANO. 


Fig.   S2I. 


Anal  fistula'  are  the  result  of  the  breaking-down  of  inflammatory  deposits 
beside  the  anus  or  lower  rectum.     They  show  no  tendency  to  heal  because 


420  FISTULA    IN  ANO. 

of  the  absence  of  cleanliness  and  of  rest,  incident  to  their  relation  with  the 
sphincter  and  the  pelvic  diaphragm. 

1.  Complete  fistulce.  have  openings  both  in  the  skin  and  mucous  membrane 
of  the  gut. 

When  the  fistula  consists  of  a  comparatively  straight  tube  leading  from 
the  skin  to  the  gut  its  operative  treatment  is  simple. 

The  Operation. — Prepare  as  for  haemorrhoid  operation  (see  page  416). 
Place  the  patient  in  the  lithotomy  position  or  on  his  left  side  with  the  right 
thigh  flexed  and  separated  from  the  left. 

Shave  and  cleanse  the  parts.  Introduce  a  fine  and  fairly  pliable  grooved 
director  into  the  opening  in  the  skin  and  pass  it  through  the  fistula  into  the  gut. 
Pass  the  forefinger  of  the  left  hand  through  the  anus  and  hook  it  over  the 
point  of  the  director.  Bring  the  point  of  the  director  with  the  finger  out 
through  the  anus.  Pass  a  probe-pointed  bistoury  along  the  grooved  director 
and  cut  through  all  the  tissues  covering  it.  The  fistulous  canal  is  now  a  gutter — 
open  throughout  its  whole  course.  With  a  sharp  spoon  scrape  away  the 
granulation  tissue  lining  the  fistulous  track.  Wash  the  wound  with  an  anti- 
septic solution  and  rub  in  a  little  iodoform  powder.  Loosely  pack  the  wound 
with  iodoform  gauze  to  compel  healing  from  the  bottom  up.  Apply  dressings. 
Keep  the  bowels  locked  up  for  four  days  and  then  open  them  with  a  dose  of 
castor  oil.  The  wound  requires  frequent  dressing  after  the  bowels  are  allowed 
to  move.  The  above  description  applies  to  a  very  simple  case;  where  the 
openings  are  multiple  the  operation  becomes  more  severe. 

Operation  Where  the  Fistula  has  Several  Internal  and  External  Openings. — 
Pass  a  director  through  the  principal  fistulous  track  and  divide  as  described 
above.  From  this  main  incision  make  secondary  incisions  so  as  to  open  up 
the  other  fistulous  tracks  and  openings.  Thus  all  the  internal  openings  are 
joined  together  and  all  the  external  openings  are  joined  together.  It  is  im- 
portant to  make  but  one  cut  through  the  sphincter  and  that  at  right  angles  to  the 
muscular  fibres.  This  is  to  avoid  dangers  of  subsequent  incontinence  of  faeces. 
When  the  mucous  membrane  of  the  gut  is  much  undermined  by  the  disease, 
gently  scrape  away  the  infected  tissue  and  if  the  mucous  membrane  covering 
it  is  thin,  incise  or  excise  the  thin  portion,  if  thick  leave  it  alone. 

Scrape  away  diseased  granulation  tissue,  wash  the  wound,  rub  in  iodoform 
powder,  pack  loosely  with  iodoform  gauze  and  dress. 

If  the  packing  of  gauze  plugs  the  anus  so  that  the  passage  of  flatus  is  inter- 
fered with,  it  is  wise  to  introduce  a  small  hard  rubber  tube  through  the  dressings 
and  the  anus  so  that  gases  may  escape  at  any  time.     (Esmarch.) 

2.  Blind  external  fistulce  have  external  but  no  internal  openings.  If  the  fistula 
is  shallow  and  recent,  one  may  enlarge  the  external  opening,  scrape  away  dis- 
eased granulation  tissue  and  pack  the  resulting  wound  with  iodoform  gauze 
to  encourage  healing  from  the  bottom  up.  Injection  of  the  fistula  with 
Beck's  bismuth  paste  is  often  recommended.     Rest  may  be  secured  by  dilating 


FISTULA   IN   ANO. 


421 


the  sphincter  and  to  temporarily  paralyzing  it.     This  mild  treatment  is  not 
often  indicated. 

The  Operation. — After  preparing  the  patient  as  already  described,  intro- 
duce the  fine  grooved  director  into  the  fistula.  Pass  the  index  finger  of  the 
left  hand  into  the  rectum.  With  the  director  and  finger  find  the  point  where 
the  fistula  most  nearly  reaches  the  gut.  Forcibly  bore  or  push  the  director 
through  the  intervening  structures  into  the  gut  protecting  the  latter  with  the 
finger.     The  rest  of  the  operation  is  the  same  as  for  complete  fistula. 

3.  Blind  internal  fistula  have    internal    but    no    external    openings. 

The  Operation. — The  patient  having  been  properly  prepared  as  already 
described  introduce  a  suitable  speculum  (generally  a  bivalve  speculum)  into 
the  gut  and  find  the  opening  of  the  fistula.  Through  the  opening  pass  a  probe 
outwards  towards  the  skin.  Using  the  point  of  the  probe  as  a  guide  cut  through 
the  skin  and  convert  the  blind  internal  into  a  complete  fistula.  The  rest  of 
the  operation  is  the  same  as  that  for  a  complete  fistula. 

4.  Excision  of  Fistula. — Incise  the  fistula  (complete  or  incomplete)  as 
already  described.  With  forceps,  scalpel  and  scissors  remove,  if  possible  en 
masse,  all  the  sclerosed  diseased  tissues  sur- 
rounding the  fistula.  Attend  to  haemostasis. 
With  sutures  close  the  whole  wound.  This 
is  best  done  by  suturing  in  layers  with  a 
continuous  suture  of  fine  catgut.  The  first 
series  of  sutures  should  be  confined  to  the 
deep  wound  and  not  touch  either  the  mucosa 
or  the  skm ;  the  two  latter  structures  should 
be  closed  by  separate  superficial  sutures. 
If  the  sutures  closing  the  deep  wound  pass 

through   the  mucous  membrane  or  skin,  they  are  liable  to  conduct  infection 
into  the  deep  structures. 

Thrailkill  excises  fistulae  as  follows:  Pass  the  probe  of  the  "safety-pin  spring 
probe"  through  the  fistula  into  the  rectum,  catch  the  end  of  the  probe  on  to  its 
hook.  (Fig.  522.)  By  taking  hold  of  the  handle  of  the  instrument,  the  fistu- 
lous tract  and  wall  can  be  firmly  held  while  the  diseased  tissue,  threaded  on 
the  probe,  is  dissected  out  in  one  piece. 


Fig. 


CHAPTER   XXXVI. 
ASCITES. 

Ascites.— Ascites  may  be  due  to  many  causes,  notably  to  cirrhosis  of  the 
liver.  In  this  disease  interference  with  the  portal  circulation  is  supposed 
to  cause  the  ascites  by  damming  back  the  blood  coming  from  the  abdominal 
viscera  to  the  liver.  Rolleston  and  Turner  argue  that  ascites  does  not  occur 
when  the  blood  pressure  is  presumably  highest  in  the  portal  vein,  i.  e.,  early  in 
the  disease;  that  ligation  of  the  portal  vein  does  not  necessarily  cause  ascites; 
that  ascites  is  probably  rather  a  result  of  a  toxaemia  than  a  mere  mechanical 
result  of  increased  blood  pressure.  These  observers  think  that  any  good 
obtained  by  omentopexy  is  due  (a)  to  a  diminution  of  the  blood  flowing 
through  the  liver  permitting  the  liver  cells  to  purify  the  blood  passing  through 
it  more  satisfactorily;  (b)  to  an  increase  of  the  arterial  supply  of  the  liver, 
through  new  formed  adhesions,  this  increased  nutrition  to  the  liver  cells  favor- 
ing their  compensatory  hypertrophy. 

Operations  for  ascites  may  be  divided  into  two  classes:  I.  Operations 
aiming  at  the  prevention  of  the  effusion  of  the  fluid.  II.  Operations  aiming 
at  the  removal  of  the  effused  fluid. 

I.  Morison-Talma  Operation.     Omentopexy.     Epiplopexy. 

Long  ago  it  was  noted  that  after  repeated  removals  of  ascitic  fluid  by  means 
of  the  trocar  and  cannula,  recovery  occasionally  took  place.  This  recovery 
was  ascribed  to  the  passage  of  some  of  the  portal  blood  into  the  systemic 
circulation  through  adhesions  formed  between  the  intraabdominal  viscera 
and  the  parietes.  Talma  and  Rutherford  Morison  (the  latter  aided  and 
abetted  by  Drummond)  each  independently  decided  to  open  the  abdomen 
and  in  a  definite  fashion  establish  adhesions  between  the  viscera  and  the 
parietes. 

Step  I. — Open  the  abdomen  near  the  middle  line  above  the  umbilicus. 
Encourage  all  the  ascitic  fluid  to  escape.  Mop  out  the  fluid  from  the  pelvis 
and  the  renal  pouches  with  gauze. 

Step  2.- — With  gauze  rub  the  upper  surface  of  the  liver  vigorously  enough  to 
favor  the  formation  of  adhesions  between  it  and  the  diaphragm.  Do  the 
same  to  the  spleen. 

Step  3. — Method  A. — Pull  the  omentum  into  the  wound  and  unite  it  to 
the  anterior  parietal  peritoneum  in  the  following  manner:  Evert  one  edge 
of  the  abdominal  wound  so  as  to  expose  the  anterior  parietal  peritoneum 
to  a  point  far  from  the  middle  line.  This  is  easy  because  the  belly  wall 
which  was  much  distended  by  the  ascites  is  now  quite  lax  after  the  removal  of 
the  fluid. 

422 


OMENTOPEXY,  423 

Suture  the  edge  of  the  omentum  to  the  parietal  peritoneum  as  far  from 
the  middle  line  as  possible.  Continue  this  suture  until  the  middle  line  is 
reached.     Do  the  same  on  both  sides. 

Method  B. — After  everting  the  anterior  belly-wall  as  in  Method  A,  make 
a  transverse  incision  through  the  peritoneum  and  suture  the  edge  of  the  omen- 
tum into  this  transverse  wound. 

Step  4. — Close  the  abdomen  with  or  without  drainage. 

On  the  whole,  the  results  of  the  Morison-Talma  operation  have  been  very 
fair.  The  death  rate  has  been  high — approximately  20  per  cent. — but  one  must 
remember  that  any  patient  requiring  the  operation  is  at  best  "a  bad  risk." 
The  best  results  have  been  obtained  in  patients  operated  on  early;  some  of  the 
results  have  been  most  gratifying. 

In  the  "American  Journal  of  Surgery"  (June,  1909)  are  published  the 
following  statistics  of  omentopexy  and  its  modifications:  1565  cases;  30.4 
per  cent,  cured;  19.8  per  cent,  relieved;  39.2  per  cent,  not  relieved;  10.6  per 
cent.  died.  "  The  greatest  variation — 5  to  23  per  cent. — is  in  the  percentage  of 
deaths,  and  this  is  found  to  depend  on  the  variation  in  the  length  of  the 
post-operative  period  on  which  the  different  mortality  statistics  were  based." 

Bindi  thinks  that  omentopexy  not  only  produces  new  and  free  anatomical 
connections  between  the  portal  and  systemic  circulation  but  that  it  awakens 
and  increases  the  absorbent  power  of  the  peritoneum. 

Maiochi  reported  seventeen  cases  of  operation  for  cirrhosis  (ascites)  without 
death  due  to  operation.  Some  of  the  cases  were  observed  for  five  years  and 
four  seemed  to  be  cured  of  their  symptoms. 

Schiassi's  Method. — "Schiassi  makes  a  vertical  incision  a  little  below  the 
left  costal  margin  opposite  the  middle  of  the  clavicle,  and  another  one  running 
outwards  from  the  upper  end  of  the  first  incision.  A  triangular  flap  consisting 
of  all  the  tissues  to  the  peritoneum  is  then  raised,  and  a  vertical  incision  made 
in  the  peritoneum.  The  spleen  and  the  great  omentum  are  withdrawn  suffi- 
ciently to  allow  the  surgeon  to  fix  them  in  the  wound  which  is  then  sutured" 
(Jacobson  and  Rowlands). 

Mayo's  Method. — Mayo  makes  an  "incision  on  the  right  side  over  the 
liver,  in  line  with  the  deep  epigastric  and  internal  mammary  vessels  so  as  to 
explore  its  surface.  A  second  incision  is  made  four  inches  below  this  through 
the  rectus  muscle  but  not  through  its  posterior  sheath.  The  posterior  sheath 
is  extensively  separated  from  the  muscle  and  a  portion  of  the  omentum  drawn 
out  of  the  upper  incision  and,  with  a  pair  of  forceps,  pulled  down  into  the 
pocket,  bringing  it  directly  in  contact  with  the  larger  vessels.  This  can  be 
i^epeated  on  the  opposite  side  and  the  intervening  segment  attached  to  the 
whole  front  of  the  parietal  peritoneum  after  the  plan  of  Morison." 

Narath's  Method. — Narath  has  modified  the  Talma-Morison  operation  as 
follows  ("Zentralblatt  fur  Chir.,"'  1905,  No  32): 

I.  Under  local  anaesthesia  open  the  abdomen  just  above  the  umbilicus  and 
to  the  left  of  the  round  ligament. 


424  ASCITES. 

2.  Thoroughly  drain  away  the  ascitic  fluid  from  all  dependent  parts  of  the 
abdomen. 

3.  Pick  up  and  pull  out  of  the  wound  a  large  segment  of  omentum.  This 
omentum  should  be  well  provided  with  vessels  and  its  pedicle  should  be  as 
thick  or  thicker  than  a  finger.  The  tension  exerted  on  the  omentum  must 
not  be  so  great  as  to  disturb  the  position  or  motility  of  the  transverse  colon. 

4.  With  sutures  partially  close  the  wound  in  the  peritoneum  and  abdominal 
fascia  being  careful  not  so  cause  pressure  on  the  protruding  omentum.  With 
a  few  fine  sutures  anchor  the  pedicle  of  omentum  to  the  peritoneum. 

5.  By  blunt  dissection  form  a  subcutaneous  pocket  to  the  left  of  the  wound 
and  into  this  pocket  tuck  the  4  or  5  inches  of  omentum  which  protrude  through 
the  belly-wall. 

6.  Close  the  cutaneous  wound  and  apply  dressings  which  will  not  injuri- 
ously press  upon  the  omentum  in  its  subcutaneous  position. 

Corson  ("Annals  Surg.,"  Dec,  1907)  is  an  enthusiastic  advocate  of  Narath's 
method.  For  reasons  which  will  be  given  later  the  author  believes  this  modi- 
fication of  omentopexy  to  be  valuable. 

A  number  of  surgeons,  notably  Delageniere,  advocate  performing  cholecys- 
tostomy  in  addition  to  omentopexy,  //"the  patient's  general  condition  justifies 
this  additional  step  it  is  calculated  to  be  of  some  value. 

Encouraged  by  the  success  following  omentopexy  and  believing  that  success 
to  be  due  to  the  passage  of  blood  from  the  portal  to  the  systemic  circulation 
through  the  omental  adhesions,  some  surgeons  sought  for  a  more  direct 
method  "of  attaining  the  same  end.  The  experiments  of  Eck  showed  the 
feasibility  of  establishing  an  anastomosis  between  the  portal  vein  and  the 
inferior  vena  cava.  Tansini  proposed  applying  this  procedure  to  man  and 
Vidal  was  the  first  to  carry  it  out.  Unfortunately,  as  Guibe  writes,  "this 
operation  ought  to  be  abandoned  because,  however  efiicient  it  may  be,  it 
exposes  the  patient  to  too  great  dangers,  the  danger  of  alimentary  intoxica- 
tion which  might  possibly  be  foreseen  and  avoided,  but  specially  the  danger 
of  a  general  infection  of  intestinal  origin  since  the  intestinal  muscosa  does  not 
always  oppose  a  sufiicient  barrier  to  microbic  invasion.  The  patient  oper- 
ated on  by  Vidal  died  after  four  months  with  evident  signs  of  a  sudden 
general  infection."  A  patient  operated  on  by  Thierry  de  Martel  died  of 
anuria  in  48  hours.  Villard  and  Tavernier  anastomosed  a  mesenteric  vein  to 
the  right  ovarian  but  the  opening  became  occluded  by  a  clot. 

II.  Operations  for  ascites  aiming  at  the  removal  of  the  effused  fluid. 

Paracentesis  A  bdominalis. — The  bowels  and  bladder  have  been  emptied. 
Thoroughly  cleanse  the  abdomen.  Place  the  patient  (unless  too  weak)  in  a 
sitting  posture.  Place  a  binder  around  the  abdomen  in  such  a  manner  that 
it  can  be  continuously  tightened  by  an  assistant  standing  behind  the  patient. 
The  binder  must  be  provided  with  an  opening  in  front  through  which  the 
operation  may  be  performed.  Percuss  the  abdomen  to  find  the  limits  of 
the  contained  fluid.     Choose  the  site  of  operation,  usually  in  the  linea  alba 


handley's  operation.  425 

midway  between  the  umbilicus  and  pubis.  Anaesthetize  the  skin  by  injecting 
a  few  drops  of  weak  cocaine  solution.  Puncture  the  skin  with  a  tenotome. 
Through  the  puncture  insert  a  trocar  and  cannula  of  medium  size.  Withdraw 
the  trocar.  Permit  the  fluid  to  escape  and  as  it  escapes  have  the  binder  tight- 
ened. Should  the  patient  show  signs  of  faintness  stop  the  flow  of  fluid  until 
he  recovers. 

When  all  the  fluid,  or  as  much  as  seems  proper,  has  been  withdrawn,  remove 
the  cannula.  A  stitch  to  close  the  puncture  may  be  necessary  occasionally. 
Apply  dressings.     Keep  a  snugly  fitting  binder  around  the  abdomen. 

Permanent  Abdominal  Drainage. 

Lambotte's  Method. — Tie  a  large  knot  about  21/2  inches  from  the  end  of  a 
thick  silk  thread  about  18  inches  long.  Make  a  small  opening  into  the  abdo- 
men; introduce  the  knot  and  short  free  end  of  the  silk  into  the  peritoneal  cavity; 
close  the  deep  abdominal  wound  around  the  silk  thread.  (The  knot  in  the 
thread  is  to  prevent  the  thread  being  pulled  out  of  the  abdomen.)  With  a 
long  probe  push  or  pull  the  long  end  of  the  thread  subcutaneously  from  the 
abdominal  wound  to  about  the  middle  of  the  thigh.  In  Lambotte's  case 
there  was  great  improvement  by  the  fourtb  day.  Marked  oedema  was  noted 
along  the  course  of  the  thread.  Unfortunately  the  thread,  becoming  imbedded 
in  the  abdominal  wall,  no  longer  reached  the  peritoneum  and  thus  the  ascites 
returned. 

Handley  has  operated  in  a  similar  fashion  ("Brit.  Med.  Journ.,"  April  16, 
1910).  The  abdomen  was  opened  in  the  left  semilunar  line;  "a  stout  needle 
threaded  double  with  lyiriphangioplasty  sUk  was  now  passed  in  and  out  in  a 
series  of  loops  through  the  peritoneal  and  subperitoneal  tissues  of  the  right 
iliac  fossa  external  to  the  mesocolon.  Short  loops  of  the  silk  were  left  exposed 
within  the  peritoneal  cavity,  whence  they  could  suck  up  fluid  by  capillary  at- 
traction. The  process  was  repeated  with  two  other  threads.  The  four 
threads  were  conducted  in  the  manner  described  to  a  point  close  to  the  anterior 
superior  spine.  With  the  aid  of  a  long  probe  they  were  then  thrust  beneath 
the  outer  end  of  Poupart's  ligament  some  way  downwards  into  the  subcutane- 
ous tissues  of  the  thigh.  The  abdominal  wound  was  now  closed  in  such  a  way 
that  the  sutures  used  proved  additional  permanent  channels  for  the  escape 
of  fluid  from  the  peritoneal  cavity.  A  number  of  thick  silk  ligatures  were 
employed  taking  up  the  peritoneum  and  the  muscular  layers  of  the  abdomen 
but  leaving  out  the  skin.  These  were  tied  and  the  skin  was  then  closed  over 
them  with  a  continuous  sperficial  suture."  The  result  of  the  operation  was 
excellent.  Qildema  under  the  abdominal  skin  showed  that  the  silk  used  in 
suturing  was  acting  as  desired  but  the  right  leg  and  thigh  so  far  from  being 
oedematous  were  slightly  smaller  than  the  left.  It  seemed  as  if  the  silk  threads 
passed  into  the  thigh  were  useless.  Seven  months  after  operation  a  condi- 
tion arose  which  seemed  to  show  that  these  threads  were  useful  and 
that  drainage  had  been  taking  place  all  the  time  without  causing  evident 
oedema,  and  further  that  if  the  absorptive  power  of  the  tissues  is  normal  and 


426  ASCITES. 

the  amount  of  tluid  led  into  them  is  not  excessive,  then  oedema  need  not  be 
expected. 

Drainage  through  the  Femoral  Canal. — Acting  on  a  suggestion  made  by 
Wynter,  Handley  has  opened  the  peritoneum  through  the  femoral  canal  and 
sutured  the  edges  of  the  peritoneal  wound  to  the  surrounding  tissues  in  such 
a  manner  as  to  prevent  its  closure  if  possible.  The  skin  wound  is  of  course 
completely  closed.  The  object  of  the  operation  is  to  conduct  the  ascitic  f^uid 
into  the  subcutaneous  tissues  of  the  thigh  whence  it  may  be  absorbed. 

Although  femoral  drainage  gave  at  least  one  brilliant  result,  yet  the  new 
formed  canal  usually  becomes  closed  or  plugged  and  failure  results. 

Direct  Drainage  into  Veins. — The  vein  suitable  for  use  in  this  operation 
is  the  internal  saphenous,  for  the  following  reasons:  (i)  It  is  conveniently 
situated;  (2)  it  is  large  enough  to  permit  of  easy  manipulation;  (3)  it  is  pro- 
vided with  efficient  valves  near  its  mouth  (the  operation  is  contraindicated 
when  varicosity  of  the  vein  renders  the  valves  useless) ;  (4)  it  does  not  belong 
to  the  portal  system. 

As  a  preliminary  to  operation  always  make  sure,  by  culture  and  innocu- 
lation,  that  the  ascitic  tluid  is  sterile.     This  is  of  great  importance. 

Step  I. — Make  an  incision  in  the  inguinal  region  along  the  course  of  the 
internal  saphenous  vein.  Expose  and  liberate  the  vein  from  its  junction 
with  the  femoral  downwards  for  about  4  inches,  /.  e.,  free  enough  of  the  vein 
to  reach,  ivithout  tension,  a  point  on  the  abdomen  just  above  Poupart's 
ligament. 

Divide  the  vein  at  the  selected  point  and  ligate  the  peripheral  segment. 

Step  2. — Wash  away  blood  from  the  vein  with  warm  salt  solution.  Smear 
the  cut  end  of  the  vein  with  vaseline  and  protect  the  vein  from  drying. 

Step  3.— Open  the  abdomen  a  short  distance  above  Poupart's  ligament 
preferably  by  means  of  the  muscle-splitting  method.  With  closed  forceps 
make  a  subcutaneous  tunnel  from  the  incision  in  the  groin  to  the  abdominal 
incision.  Pass  the  mobilized  segment  of  vein  through  the  tunnel  and  suture 
its  open  end  to  the  opening  in  the  peritoneum.  This  suturing  ought  to  be  done 
after  the  Carrel  method  of  arteriorraphy,  with  vaselinized  silk. 

Step  4. — Close  the  wounds.  Before  closing  the  abdominal  wound  it  may  be 
necessary  to  divide  a  few  muscle  fibres  so  as  to  prevent  pinching  of  the  vein 
as  it  passes  through   the  parietes. 

Ruotte  ("Lyon  Chirurgical,"  March,  19 10;  "La  Presse  Med.,"  June 
25,  1 9 10)  performed  this  operation  in  January,  1907,  on  a  very  unfavorable 
subject.  For  a  month  everything  went  well  but  after  that  time  Ruotte  per- 
formed the  operation  on  the  opposite  side  and  the  patient  died  three  days 
later  from  grave  cardiac  disease. 

Ruotte's  second  patient  was  a  man  of  seventy.  The  operation  was  per- 
formed on  both  sides  at  the  same  sitting.  The  patient  remained  apparently 
well  for  over  eighteen  months  after  which  time  he  was  lost  to  sight. 

Out  of  five  patients  operated  on  by    Ruotte,  in  two  the  result  was  negative; 


REMARKS.  427 

out  of  three  operated  on  by  Ito  and  Soyesima  there  was  but  one  success,  but 
that  was  secured  in  a  man  of  thirty-eight  who  had  been  tapped  seven  times, 
been  subjected  successively  to  omentopexy,  renal  decortication  and  to  an 
attempt  at  drainage  into  the  subcutaneous  tissues  by  means  of  a  buried  cannula. 

Remarks. — Operations  which  promise  even  a  very  moderate  amount  of 
success  are  thoroughly  justifiable  in  such  a  fatal  condition  as  ascites  due  to 
hepatic  cirrhosis. 

The  patients  are  usually  in  such  poor  condition  that  they  are  incapable 
of  withstanding  any  severe  intervention. 

Narath's  modification  of  omentopexy  seems  superior  to  the  Talma-Mori- 
son  operation  in  that  it  probably  establishes  a  permanent  and  efficient  drainage 
of  the  ascitic  fluid  into  the  subcutaneous  tissues  by  means  of  the  herniated 
omentum. 

Wynter's  remarks  quoted  by  Handley  are  very  weighty: 

"The  treatment  of  ascites  by  repeated  paracentesis,  commonly  employed 
in  hepatic  cirrhosis,  has  proved  unsatisfactory,  inasmuch  as  in  the  majority 
of  cases  the  fluid  returns  within  a  few  days,  and  the  patient  is  confined  to  bed 
or  hospital  for  the  remaining  brief  period  of  life,  which  seldom  extends  beyond 
two  or  three  months. 

"The  steady  downhill  course  and  rapid  loss  of  strength  after  paracentesis 
has  been  inaugurated  indicate  that  the  patient  pays  dearly  for  the  relief  of 
distention  by  the  sacrifice  of  so  much  nutrient  fluid,  whose  speedy  replace- 
ment drains  the  blood  and  tissues  and  starves  the  kidneys.  The  objects  aimed 
at  by  the  method  of  subcutaneous  drainage  are: 

"i.  The  saving  of  nutrient  material  to  the  patient. 

"2.  To  ensure  an  adequate  outflow  of  urine  from  the  kidneys  and  a  sufl&- 
cient  supply  of  fluid  to  the  tissues  by  draining  the  stagnant  pond  of  the  perit- 
oneal cavity. 

"3.  To  enable  the  patient  to  leave  his  bed  and  to  maintain  the  circulation 
of  the  body  fluids,  especially  in  the  portal  and  lymphatic  systems,  by  means  of 
exercise. 

"4.  To  relieve  intraabdominal  tension,  and  thus  promote  lymphatic  absorp- 
tion and  the  establishment  of  a  good  collateral  circulation." 

To  the  author  it  appears  that  much  of  the  good  obtained  from  omentopexy 
may  be  attributed  to  permanent  drainage  accidentally  established;  that  some 
form  of  subcutaneous  drainage  will  prove  the  treatment  of  choice;  that  all 
endeavors  after  direct  anastomosis  between  the  hepatic  and  systemic  cir- 
culation are  unjustifiable. 


CHAPTER  XXXVII. 


THE  PANCREAS. 


The  pancreas  is  so  deeply  hidden  behind  the  abdominal  cavity  that  it 
has  been  much  neglected  even  by  the  pathological  anatomists.  The  fact 
that,  when  it  is  injured,  other  organs  are  always  notably  injured  at  the  same 
time,  and  the  patient  is  evidently  in  a  critical  condition,  has  led  operators  to 
neglect  direct  investigation  or  inspection  of  the  gland.  Until  very  recently 
the  only  pancreatic  lesions  attacked  by  surgery  were  cysts.  To-day,  thanks 
to  the  labors  of  many  pathologists,  internists,  and  surgeons,  more  knowledge 
has  been  attained  and  this  "hermit  kingdom"  is  being  opened  up  to  surgical 
therapy. 


Tranavcrae  Colo 


Fig.  523. — Anatomical  Relations  of  the  Pancreas.- — (Mayo.) 


The  pancreas  reaches  from  the  duodenum  to  the  spleen  and  discharges 
its  secretions  through  the  canal  of  Wirsung  into  the  duodenum.  Before 
entering  the  gut  the  canal  of  Wirsung  unites  with  the  common  bile-duct  to 
form  the  diverticulum  or  ampulla  of  Vater  (Fig.  523).  Besides  the  main  duct 
or  canal  of  Wirsung,  there  is  a  secondary  duct  (duct  of  Santorini),  which  arises 
from  the  main  duct  near  the  head  of  the  gland  and  discharges  into  the  duo- 
denum at  a  slightly  higher  level.  The  tail  or  left  extremity  of  the  pancreas 
lies  in  front  of  the  left  kidney  and  the  suprarenal  capsule.      The  most  impor- 

428 


THE    PANCREAS. 


429 


tant  vascular  relations  of  the  pancreas  are  the  splenic  artery  on  its  upper  sur- 
face, while  at  its  head  is  the  pancreatico-duodenal  artery,  which  forms  an 
arch  with  the  superior  mesenteric.  The  pancreas  lies  behind  the  posterior 
parietal  peritoneum  and  in  front  of  the  lower  portion  of  its  head  is  the  trans- 
verse mesocolon;  in  front  of  its  body  is  the  stomach. 

There  are  several  routes  by  which  the  pancreas  may  be  reached:     (i) 
Through  the  gastro-hepatic  omentum  above  the  stomach;   (2)   through  the 


Fig.  524.  Fig.  525.  Fig.  526. 

Fig.  524. — ^Tumor  of  pancreas.  Stomach  and  colon  both  below  it. — {Robson  and 
Moynihan.) 

Fig.  525. — Tumor  of  pancreas.  Stomach  and  colon  both  in  front  of  \\..^{Robson  and 
Moynihan^ 

Fig.  526. — ^Tumor  of  pancreas  pushing  forwards  between  the  posterior  layer  of  the  great 
omentum  and  the  transverse  mesocolon.  Stomach  above,  colon  beneath,  it. — (Robson  and 
Moynihan.) 

gastro-colic  omentum  below  the  stomach;  (3)  through  the  transverse  meso- 
colon back  of  colon  and  the  stomach;  (4)  by  retracting  inwards  the  second 
part  of  the  duodenum;  (5)  through  the  stomach;  (6)  from  the  loin  behind  the 
peritoneum. 

Operation  upon  a  pancreatic  cyst  forms  a  good  type  on  which  to  base  a 
description  of  surgical  interference. 

Step  I. — Open  the  abdomen  in  or  near  the  middle  line  above  the  umbilicus. 
If  the  cyst  makes  a  prominent  swelling,  it  may  be  well  to  make  the  incision, 
vertically,   over  its  most  prominent  part.     Explore  the  abdomen,  note  the 


43° 


THE    PANCREAS. 


presence  and  extent  of  adhesions,  and  where  the  cyst  presents.  This  may 
be  above,  behind  or  below  the  stomach,  behind  or  below  the  transverse  colon 
(Figs.  524,  525,  526,  527,  528.) 

Step  2. — (A)  The  cyst  presents  or  is  most  prominent  above  or  behind 
the  stomach.  Make  a  vertical  tear  through  the  gastro-hepatic  omentum; 
this  at  once  exposes  the  cyst.  Endeavor  to  explore  the  relations  of  the  cyst, 
but  do  not  persist  in  the  exploration  if  great  difficulties  arise,  lest  harm  result. 
In  a  few  instances  it  may  be  found  possible  to  excise  the  disease;  most  com- 
monly marsupialization  is  the  operation  of  choice. 


Fig.  527. 
Tumor  of   pancreas, 
front,    colon   below,    it- 
Moynihan.) 


Stomach  in 
-{Robs on  and 


Fig.  528. 
Tumor  of  pancreas.     Stomach  and 
colon    both    above    it. — (Robson    and 
Moynihan.) 


(B)  The  cyst  presents  between  the  stomach  and  transverse  colon,  behind 
the  colon,  or  behind  the  stomach.  Make  a  vertical  tear  through  the  gastro- 
colic omentum  and  expose,  explore,  and  treat  the  cyst.  J.  D.  Malcolm  ("Lan- 
cet," June  16,  1906)  completely  and  successfully  removed  a  multilocular  cystic 
tumor  through  this  route.  Both  layers  of  the  transverse  mesocolon  were 
divided;  the  wound  in  the  inferior  layer  was  sutured.  Although  the  pancreas 
itself  was  incised  this  gave  no  subsequent  trouble,  probably  because  drainage 
was  established  posteriorly  below  the  twelfth  rib.  Acute  flexion  at  the  splenic 
angle  of  the  colon  necessitated  colo-colic  anastomosis  on  the  sixteenth  day 
after  the  primary  operation.     Recovery. 


THE    PANCREAS.  43 1 

(C)  The  cyst  presents  behind  or  below  the  transverse  colon.  Pull  the  trans- 
verse colon  and  great  omentum  out  through  the  belly  wound  and  turn  them 
upwards  exactly  as  is  done  in  posterior  gastro-enterostomy.  In  an  avascular 
area  of  the  transverse  mesocolon  make  an  appropriate  tear  and  expose,  ex- 
plore, and  treat  the  cyst.  Do  not  injure  the  mid-colic  artery  or  any  of  its 
main  branches. 

(D)  Korte  has  reached  the  head  of  the  pancreas  by  forcing  his  way  along 
the  side  of  the  duodenum  after  incising  its  peritoneal  covering.  This  is  very 
similar  to  Vautrin's  method  of  reaching  the  lowest  segments  of  the  common 
bile-duct. 

(E)  Transgastric  route:  Hagen  ("Archiv  f.  klin.  Chir.,"  Ixii,  157)  reports 
a  case  in  which  complications  compelled  him  to  attack  the  cyst  after  incision 
of  both  the  anterior  and  posterior  gastric  walls.  The  stomach  was  insepa- 
rably and  indistinguishably  adherent  to  the  cyst.  It  was  impossible  to  reach 
the  cyst  and  bring  a  portion  of  its  wall  to  the  parietes  by  any  ordinary  means. 
Hagen  made  a  two-inch  incision  through  the  anterior  wall  of  the  stomach  and 
a  small  one  through  the  posterior  wall.  There  was  no  Ime  of  demarcation 
between  the  stomach  and  cyst-walls.  After  evacuation  of  the  contents  the 
cyst  was  explored  with  the  linger.  It  was  possible  with  care  to  bring  a  small 
area  of  cyst-wall  to  the  parietes,  to  the  left  of  the  great  curvature,  below  the 
ribs,  behind  the  left  gastro-epiploic  artery  and  vein.  Before  the  selected 
portion  of  cyst-wall  could  be  united  to  the  parietes  it  was  necessary  to  resect 
the  cartilages  of  the  ninth  and  tenth  ribs  on  the  left  side;  this  permitted  the 
soft  belly-wall  to  sink  inwards  and  meet  the  cyst-wall  as  it  was  elevated. 
Closure  of  the  gastric  wound  by  suture  and  marsupialization  of  the  cyst  com- 
pleted the  operation.  Recover}-.  Hagen  considered  the  possibility  of  lumbar 
drainage,  but  in  his  case  it  was  out  of  the  question. 

(F)  Lumbar  route:  Remember  that  the  tail  of  the  pancreas  lies  in  front 
of  the  left  renal  vessels,  hence  any  portion  by  which  the  hilus  of  the  kidney  is 
exposed  will  also  give  access  to  the  left  extremity  of  the  pancreas.  Exposure 
of  the  kidney  through  the  loin  is  so  fully  discussed  elsewhere,  and  exposure  of 
the  tail  of  the  pancreas  is  so  similar,  that  further  description  is  unnecessary' 
here. 

In  the  course  of  transperitoneal  operations  it  is  often  advisable  or  necessary 
to  provide  lumbar  drainage.  To  effect  this,  explore  the  cyst  with  the  finger; 
guided  by  the  finger  and  carefully  avoiding  all  important  structures  such  as  the 
renal  vessels,  etc.,  push  a  closed  forceps  through  the  posterior  parietes  below 
the  twelfth  rib  and  immediately  external  to  the  erector  spinae  muscle.  Incise 
the  skin  and  deep  fascia  at  the  point  made  prominent  by  the  forceps.  Make 
the  opening  large  enough  to  avoid  compression  of  the  tube  or  gauze  used  for 
drainage.  With  the  forceps  pull  a  drain  (gauze  or  tube)  into  position.  It  is 
well,  when  preparing  a  patient  for  any  operation  on  the  upper  half  of  the 
belly,  in  which  posterior  drainage  may  be  required,  to  follow  Park's  advice, 
and  clean  the  lumbar  region  as  well  as  the  abdomen;  thus  valuable  time  may 


432 


THE  PANCREAS. 


be  saved  in  the  course  of  the  operation.  Deaver's  plate  (Fig.  529),  although 
drawn  to  illustrate  the  relations  of  the  kidney,  illustrates  the  important  ana- 
tomical relations  of  the  pancreas,  especially  with  regard  to  exposure  through 
the  lumbar  route.  Only  the  head  and  tail  of  the  pancreas  are  accessible  by 
this  posterior  route,  the  tail  being  more  easily  reached  than  the  head.  Peters 
was  successful  in  exposing  and  draining  a  hydatid  cyst  of  the  tail  of  the  pancreas 
through  the  left  lumbar  route. 

Step  3. — Treatment  of  the  cyst.  Dangers:  The  dangers  inseparable  from 
operations  on  the  pancreas  are  less  pronounced  in  cystic  than  in  other  diseases 
or  lesions.  It  will  be  convenient,  however,  at  this  time,  to  discuss  the  dangers 
of  pancreatic  operations  in  general;  v.  Mikulicz  gives  a  good  resum^  of  these 


*'^».i'*'' 
^<^^'-" 


Fig.  529. — (Deaver.) 


in  his  paper  on  "The  Surgery  of  Trauma  and  Inflammatory  Processes  in  the 
Pancreas"  ("Transactions  of  the  Congress  of  American  Physicians  and 
Surgeons,"  1903). 

1.  Hemorrhage.  The  pancreas  is  exceedingly  vascular;  its  tissues  are 
fragile,  and  hence  simple  ligature  is  often  entirely  ineffective.  Sutures  involv- 
ing a  mass  of  healthy  or  uninjured  tissue,  as  well  as  the  bleeding  area,  are 
necessary  in  spite  of  the  dangers  from  necrosis  incident  to  the  use  of  mass 
ligatures.  Secondary  hemorrhage  is  common.  It  is  wise,  when  possible, 
to  prepare  the  patient,  prior  to  operation,  by  the  exhibition  of  large  doses  of 
chloride  of  calcium,  as  recommended  by  Mayo  Robson  in  cases  of  jaundice. 

2.  Leakage  of  pancreatic  juice  into  the  parenchyma  of  the  gland  and  the 
surrounding  peritoneal  structures  constitutes  a  greater  danger  even  than  bleed- 
ing. The  juice,  even  when  sterile,  does  much  positive  damage;  it  also  di- 
minishes the  resisting  power  of  the  tissues  so  that  the  mildest  form  of  infection, 
ordinarily  harmless,  becomes  of  the  gravest  significance.  Infection  is  liable 
to  reach  the  injured  area  through  the  pancreatic  duct  from  the  duodenum  in 
the  same  manner  as  it  passes  up  the  common  bile-duct.  Fat  necrosis  and 
pancreatitis,  both  chronic  and  hemorrhagic,  may  be  occasioned  by  trauma, 
and  hence  may  result  from  operation.     Peritonitis  is  very  liable  to  result  from 


PANCREATITIS.  433 

pancreatic  leakage.  This  peritonitis  may  be  aseptic  and  is  frequently  fol- 
lowed by  intestinal  paralysis,  leading  to  rapidly  developing  obstruction,  which 
often  so  modifies  the  symptoms  as  to  lead  to  a  serious  mistake  in  diagnosis 
(v.  Milkulicz) .  During  excision  of  gastric  cancer  portions  of  the  adherent 
pancreas  may  be  shaved  away,  hemostasis  being  attained  by  sutures  and  by 
covering  the  wound  with  peritoneum.  The  fact  does  not  negative  the  value 
of  the  preceding  remarks  as  in  gastric  cancer  where  portions  of  the  pancreas 
must' be  sacrificed,  these  portions  have  been  subjected  to  simple  or  adhesive 
inflammation  and  thus  are  prepared  for  operation. 

3.  It  has  been  shown  that  by  the  time  such  definite  symptoms  of  pancreatic 
disease  arise  "as  diabetes  or  severe  disturbance  of  its  fat-digesting  function, 
there  is,  as  a  rule,  already  such  great  destruction  of  its  substance  that  surgical 
interference  is  not  admissible.  The  author  operated  on  one  case  of  very 
recent  pancreatic  diabetes  in  the  hope  that  drainage  might  relieve  the  inflam- 
mation to  which  it  was  believed  the  disease  was  due;  the  patient  did  not  survive 
more  than  twenty-four  hours.  Nash  ("Lancet,"  Nov.  i,  1902)  reports  a  case 
of  pancreatic  glycosuria  associated  with  cholelithiasis  in  a  man  of  sixty  years. 
After  removal  of  a  large  calculus  from  the  gall-bladder,  recovery  ensued.  The 
urine  four  months  after  operation  was  free  from  sugar.  In  Woolsey's  three 
successful  operations  for  acute  pancreatitis  only  one  had  glycosuria. 

Mayo  Robson  ("Brit.  Med.  Journ.,"  April  23,  1910)  after  discussing 
the  value  of  Cammidge's  reaction  as  a  means  of  diagnosing  pancreatic 
disease  before  and  after  the  appearance  of  glycosuria,  comes  to  the  following 
conclusions: 

1.  That  the  early  recognition  and  treatment  of  interstitial  pancreatitis, 
or  of  pancreatic  catarrh,  by  drainage  of  the  bile-ducts,  and  thus  indirectly  of 
the  pancreatic  ducts,  and  the  removal  of  the  cause,  whether  that  be  gall-stones, 
duodenal  ulcer,  or  other  conditions,  may  be  the  means  of  averting  diabetes. 

2.  That  in  certain  diseases  of  the  pancreas,  even  after  the  appearance  of 
glycosuria,  surgical  treatment  is  well  worth  considering,  as  in  a  number  of 
cases  it  has  lead  to  a  complete  disappearance  of  sugar  from  the  urine,  and  in 
others  to  an  arrest  of  the  disease  causing  glycosuria. 

3.  That  every  case  of  diabetes  should  be  considered  from  its  etiological 
point  of  view,  seeing  that  certain  cases  of  glycosuria  of  pancreatic  origin  are 
curable,  and  in  others  the  progress  of  the  disease  may  be  arrested  by  suitable 
surgical  methods  that  can  be  carried  out  with  small  risk. 

Robson  reports  a  number  of  cases  which  support  these  conclusions. 

(A)  Excision  of  the  Cyst. — This  operation  is  suitable  only  in  cases  where  ad- 
hesions are  few  or  where  the  cyst  has  become  pedunculated.  Ransohoff  has 
collected  23  cases  of  enculeation  with  2  deaths.  The  operation  requires  no 
special  description,  as  the  surgeon  must  follow  the  common  principles  of  surgery 
after  the  tumor  has  been  exposed  by  one  of  the  methods  described  above,  v. 
Mikulicz  lays  down  the  absolute  rule  that  whenever  the  pancreatic  tissue  has 
been  exposed,  drainage  is  requisite. 

28 


434  THE    PANCREAS. 

(B)  Marsupialization  or  Drainage. — Expose  the  cyst  by  any  of  the  methods 
described.  Protect  the  peritoneal  cavity  thoroughly  with  pads.  Note  the 
part  of  the  cyst  which  can  be  most  readily  brought  into  apposition  with  the 
abdominal  wall .  If  the  site  of  the  primary  abdominal  incision  proves  unsuitable, 
a  secondary  incision  may  be  made.  If  the  cyst  is  very  tense,  empty  it,  at  least 
in  part,  by  means  of  the  aspirator.  Suture  the  cyst-wall  to  the  parietal  perit- 
oneum. Explore  the  cyst  cavity.  E^specially  note  if  the  tumor  is  a  true 
pancreatic  cyst,  /.  e.,  one  arising  in  the  gland  itself;  or  a  false  one,  i.  e.,  a  col- 
lection of  fluid  in  the  lesser  peritoneal  cavity  due,  as  a  rule,  to  injury  or  disease 
of  the  pancreas.  If  necessary,  provide  drainage  by  means  of  lumbar  puncture 
Provide  tubular  or  gauze  drainage  of  the  cyst  or  a  combination  of  tubular  and 
gauze  drainage.  If  the  cyst-wall  is  of  suitable  consistency,  it  is  well  to  fix  a 
"dressed  drainage-tube"  into  it,  exactly  as  is  done  in  the  case  of  the  gall-bladder. 
If  the  cyst-wall  is  too  thin  to  be  sutured  with  safety  to  the  parietes.or  if  it  can- 
not be  brought  to  the  abdominal  wound,  protect  the  peritoneum  with  gauze 
packing  around  a  tube  which  leads  into  the  cyst.  As  a  whole,  the  methods 
of  draining  pancreatic  cysts  are  identical  with  those  for  draining  the  gall- 
bladder, but  in  the  case  of  the  former  greater  danger  is  to  be  feared  from  the 
effects  of  the  leakage  of  fluid  into  the  peritoneum.  Having  provided  for  drain- 
age, close  the  excess  of  wound  in  the  abdominal  wall. 

Usually,  under  the  above  treatment,  the  cyst  shrinks  and  becomes  ob- 
literated.    Occasionally  a  fistula  persists. 

Wohlgemuth  and  Karewsky  have  found  that  persistent  pancreatic  fistulae 
close  promptly  when  the  patients  are  put  on  rigid  antidiabetic  diet.  Walter 
Schmidt  ("Muench.  med.  Woch.,"  Dec.  lo,  1907)  reports  having  excised  a 
pancreatic  cyst:  the  gland  was  injured,  drainage  provided,  antidiabetic  diet 
was  ordered;  everything  went  well  until,  on  the  thirteenth  day  after  opera- 
tion, a  more  liberal  diet  was  permitted  when  the  discharges  became  more  pro- 
fuse and  continued  so  until  the  rigorous  diet  was  reestablished. 

Solid  tumors  of  the  pancreas  are  rarely  suitable  for  operation.  Ruggi, 
in  1890,  and  Gade,  in  1895,  successfully  removed  tumors  from  the  tail  of  the 
pancreas;  most  of  the  other  cases  reported  promptly  died. 

Excision  of  the  Head  of  the  Pancreas. — The  author  is  unaware  of  any 
operation  actually  performed  for  the  excision  of  the  head  of  the  pancreas  and 
the  duodenum,  but  the  steps  of  the  operation  as  elaborated,  on  the  cadaver, 
by  Desjardins  ("Rev.  de.  Chir.,"  June,  1907)  teach  so  many  valuable  lessons 
that  the  method  demands  attention.  Various  items  of  the  operation  are  well 
calculated  to  assist  a  surgeon  when  attacking  such  conditions  as  malignant 
disease  of  the  duodenum  near  the  ampulla  of  Vater,  etc.  Desjardins  remarks 
that  if  the  length  and  complexity  of  the  operation  demands  it,  the  pro- 
cedure may  be  carried  out  in  two  sittings.  At  the  first  sitting  a  gastro-enter- 
ostomy  (en  Y)  is  done,  the  jejunum  being  divided  lower  than  usual,  about 
8  inches  from  its  origin.  At  the  second  sitting  the  head  of  the  pancreas  is 
removed  along  with  the  duodenum  and  the  double  anastomosis  of  the  bile- 


EXCISION    OF    PANCREAS.  435 

duct  and  the  pancreas  carried  out.  This  second  operation  consumes  about 
the  same  time  as  does  an  ordinary  pylorectomy. 

Desjardins'  Operation. — There  are  three  special  anatomical  dangers 
to  be  overcome  in  the  operation: 

<7.  In  certain  cases  the  upper  end  of  the  ascending  colon  lies  directly  on 
the  right  surface  of  the  descending  duodenum  and  is  hence  in  danger  of 
injury  when  the  duodenum  is  being  mobilized. 

b'.  At  the  third  portion  of  the  duodenum  the  superior  mesenteric  artery 
and  vein  emerge  from  under  the  lower  edge  of  the  pancreas  and  pass  over  the 
front  of  the  duodenum.  The  middle  colic  artery  arises  from  the  superior 
mesenteric  and  courses  through  the  transverse  mesocolon;  it  is  easily  injured 
and  injury  leads  to  gangrene  of  the  gut  it  supplies.  The  mesenteric  artery, 
lying  to  the  left  of  its  companion  vein,  is  situated  in  the  groove  which  separates 
the  body  from  the  neck  of  the  pancreas;  it  runs  downwards  and  to  the  right  in 
a  curve  which  is  convex  towards  the  left;  from  its  concave  or  right  side  as  soon 
as  it  emerges  from  the  pancreas  it  gives  off  the  colic  arteries.  To  the  left  of 
the  superior  mesenteric  vessels  there  is  an  avascular  region  in  which  there 
is  no  vessel  except  the  pancreatico-duodenal,  and  it  can  be  safely  tied. 

r.  Behind  the  pancreas  and  close  to  it,  lie  the  portal  vein  and  the  inferior 
vena  cava. 

Place  the  patient  in  Robson's  position. 

Step  I. — Make  a  median  incision  from  a  point  on  the  level  of  the  tip  of  the 
ninth  rib,  downwards  to  near  the  umbilicus.  From  the  upper  end  of  the  verti- 
cal incision  cut  upwards  and  to  the  right,  through  the  right  rectus,  until  the 
costal  margin  is  reached  above  and  to  the  inner  side  of  the  gall-bladder.  If 
more  room  is  required  make  an  oblique  cut  downwards  and  to  the  left  from 
the  lower  end  of  the  median  incision.  Before  making  the  two  supplementary 
cuts,  introduce  the  hand  and  explore  the  belly. 

Step  2. — Push  the  omentum  to  the  left.  Expose  the  duodenum.  Incise  the 
peritoneum  parallel  to  and  about  3/4  inch  from  the  descending  duodenum 
after  noting  that  it  is  not  adherent  to  the  ascending  colon.  Through  the  perit- 
oneal wound  separate  the  duodenum  from  the  posterior  belly-wall  luitil 
the  portal  vein  and  vena  cava  are  passed.  The  head  of  the  pancreas  can  now 
be  completely  explored  and  even  brought  almost  out  of  the  wound. 

Step  3. — Ligate  the  pyloric  and  gastroduodenal  vessels  as  in  pylorectomy. 
Divide,  between  ligatures,  the  right  portion  of  the  great  omentum. 

Step  4. — Doubly  clamp  and  divide  the  pylorus.  Pull  the  mobilized  duo- 
denum downwards  to  expose  the  common  bile  duct.  If  the  duct  is  dilated 
divide  it,  between  forceps,  as  low  as  possible;  if  not  dilated,  divide  it  just  be- 
low the  entrance  of  the  cystic  duct.  At  this  stage  it  may  be  necessary  to  cau- 
tiously dissect  the  mesocolon  in  order  to  disengage  the  portion  of  the  duo- 
denum lying  under  it.  Continue  the  separation  of  the  duodenum  until  the 
superior  mesenteric  vessels  are  passed  and  the  duodeno-jejunal  junction  is 
reached;  doubly  clamp  and  divide  the  gut  here. 


436 


THE    PANCREAS. 


Step  5  — The  pancreas  and  duodenum  are  still  attached  to  each  other. 
Place  a  clamp  on  the  body  of  the  pancreas.  The  clamp  must  be  directed  ob- 
liquely upwards  and  to  the  right  so  as  to  avoid  injuring  the  colic  arteries.  When 
so  placed,  the  lower  ends  of  the  clamps  are  remote  from  the  mesentery  where 
the  colic  vessels  arise.  Divide  the  pancreas  to  the  right  of  the  clamp  or  between 
the  clamps  if  two  have  been  used. 

Step  6. — Remove  the  head  of  the  pancreas  and  the  duodenum  being  careful 
not'  to  injure  the  mesenteric  vessels  which  emerge  from  between  these  structures. 


Fig.   530. —  (Desjardin.) 


Step  7. — Close  the  opening  in  the  stomach  where  the  pylorus  was  divided. 
With  a  Murphy  button  anastomose  the  open  end  of  the  jejunum  to  the  posterior 
surface  of  the  stomach. 

Step  8. — Anastomose  the  common  bile-duct  to  the  jejunum.  If  this  is 
impossible  because  of  the  small  size  of  the  duct,  close  the  duct  and  anastomose 
the  gall-bladder  to  the  jejunum. 

Step  9. — Apply  chain  sutures  to  the  cut  surface  of  the  pancreas  but  leave 
the  canal  of  Wirsung  free.     Isolate  about  i  inch  of  the  canal,  and  anastomose 


EXCISION    OF    PANCREAS. 


437 


it  to  the  jejunum.  This  anastomosis  is  very  similar  to  that  between  the  ureter 
and  the  bladder.  If  Wirsung's  duct  is  too  narrow  to  permit  of  anastomosis 
another  method  must  be  adopted;  often  a  number  of  small  ducts  wUl  be  found 
instead  of  one;  this  also  demands  a  change  in  method. 

Alternative  Method.- — ^Doubly  clamp  and  divide  the  jejunum  about  12  inches 
from  its  origin.  Opposite  the  point  of  section  free  and  divide  the  mesentery 
as  much  as  possible  without  damaging  the  blood  supply.  Anastomose 
the  distal  segment  of  gut  to  the  stomach  as  in  Step  7.    A  loop  of  jejunum 


Fig.  531. — (Desjardin.) 


now  lies  free  except  for  a  loose  mesenteric  attachment,  and  open  at  both 
ends.  Anastmose  one  end  of  this  loop  to  the  gall-bladder  after  closing  the 
common  duct;  into  the  other  open  end  of  the  segregated  loop,  push  the  divided 
end  of  the  pancreas  and  fix  it  there  by  sutures  introduced  as  nearly  as  pos- 
sible in  the  Lembert  fashion.  Make  an  anastomosis  between  the  middle  of 
the  segregated  loop  of  jejunum  and  that  portion  which  is  anastomosed  to  the 
stomach.     Provide  free  drainage  especially  in  the  pancreatic  region. 

Acute  Pancreatitis. — The  tendency  at  the  present  time  is  to   operate 


4,SS  THE    PANCREAS. 

very  early  in  this  most  fatal  disease.  The  operation  consists  in  an  exploratory 
incision  above  the  umbilicus.  In  doing  this,  be  on  the  lookout  for  patches  of 
fat  necrosis;  these  are  yellowish-white  patches  of  various  sizes  situated  in  the 
subperitoneal,  mesenteric  and  omental  fatty  tissues.  Fat  necrosis  is  always 
indicative  of  pancreatic  disease. 

According  to  indications  found  after  the  abdomen  has  been  opened,  the 
pancreas  should  be  exposed  either  through  the  great  omentum  above  the  colon, 
or  through  the  transverse  mesocolon.  The  belly  cavity  must  be  thoroughly 
protected  by  gauze  packing.  If  abscess  is  present,  the  pus  is  now  evacuated, 
if  requisite,  incision  being  made  into  the  pancreas  for  this  purpose  (case  of 
Dr.  C.  B.  Porter  of  Boston,  reported  by  v.  Mikulicz,  "Trans.  Am.  Cong. 
Phys.  and  Surg.,"  1903).  Sloughs  and  gangrenous  tissue  should  be  removed 
and  drainage  provided.  In  spite  of  all  care  and  thoroughness  in  operating, 
the  disease  continues  to  prove  most  fatal. 

Subacute  Pancreatitis. — The  operative  treatment  of  subacute  pan- 
creatitis is  practically  the  same  as  that  of  pancreatic  cysts  and  requires  no 
special  discussion.  Mayo  drained,  with  success,  one  case  of  this  nature  through 
the  gall-bladder,  as  is  done  in  chronic  pancreatitis. 

Chronic  pancreatitis  is  treated  by  cholecystostomy  or  cholecystenter- 
ostomy. 

Robson  ("Surg.,  Gyn.,  Obst.,"  Jan.,  1908)  finds  that  of  one  hundred  and 
two  operations  in  patients  in  whom  chronic  pancreatic  trouble  w^as  the  chief 
disease,  or  where  it  formed  a  serious  complication  of  other  diseases,  96.1  per 
cent,  of  cases  were  followed  by  complete  recovery,  giving  a  mortality  of  3.9 
per  cent.;  but  since  these  statistics  were  compiled  in  1904  experience  has  very 
largely  increased  and  the  mortality  has  diminished  to  a  little  over  2  per  cent. 
Of  course  where  biliary  or  pancreatic  stones  are  present  such  must  be  removed. 

Ruth  ("Colorado  Medicine,"  Oct.,  1907)  removed  a  mass  of  calculi  which 
weighed  280  grains  and  lay  throughout  the  whole  length  of  the  gland.  He  found 
the  duct  walls  1/8  inch  thick  and  very  strong. 

Pancreatic  Lithiasis. — Stones  are  formed  in  the  pancreatic  as  in  the 
biliary  duct.  Calculi  existing  near  the  ampulla  of  Vater  may  be  extracted 
through  a  duodenal  incision,  as  in  the  case  of  gall-stones.  As  a  rule,  the  re- 
moval of  pancreatic  calculi  has  been  accomplished  incidentally  during  the 
■evacuation  of  abscesses  in  subacute  pancreatitis.  Moynihan  was  the  first 
to  remove  a  calculus  where  the  diagnosis  had  been  made  prior  to  operation. 
AVhen  a  calculus  can  be  felt  in  the  exposed  pancreas  it  is  proper  to  incise  the 
gland,  remove  the  stone,  close  the  pancreatic  wound  with  sutures,  and  provide 
for  drainage. 

Traumata. — Whenever  structures  around  the  pancreas  are  injured  one 
ought  to  suspect  and  look  for  injury  to  that  organ.  When  in  a  case  of  bullet 
\yound  the  posterior  wall  of  the  stomach  is  penetrated,  it  is  extremely  probable 
that  the  pancreas  is  also  involved.  Remember,  experience  teaches  that  a 
comparatively  slight  injury  to  the  gland  may  lead  to  disastrous  results  from 


INJURIES    TO   PANCREAS.  439 

leakage  of  the  digestive  juice.  Lacerated  fragments  of  the  pancreas  must 
be  removed.  Wounds  in  its  substance  must  be  sutured  with  catgut,  care 
being  taken  not  to  occlude  the  duct  by  the  suture.  Whether  sutures  are 
used  or  not  drainage  must  be  established,  preferably  by  means  of  cigarette 
drains,  which  may  be  introduced  through  the  abdominal  wound  or  through  a 
special  lumbar  wound  or  by  both  routes.  After  the  pancreatic  lesion  has  been 
attended  to,  it  is  good  practice  thoroughly  to  douche  the  general  peritoneal 
cavity  with  hot  salt  solution  in  order  to  get  rid  of,  or  at  least  dilute,  any  effused 
pancreatic  juice. 

As  anti-diabetic  diet  diminishes  pancreatic  secretion  (Wohlgemuth),  such 
a  diet  may  be  of  very  great  value  as  an  adjuvant  to  the  local  treatment  of  in- 
juries to  the  pancreas. 


CHAPTER  XXXVIII. 
THE  SPLEEN. 

Surgical  Anatomy. — "The  spleen  is  a  soft,  highly  vascular,  and  easily 
distensible  organ,  of  a  dark,  purplish-gray  color.  It  is  placed  obliquely  in  the 
back  of  the  left  hypochondrium,  between  the  cardiac  end  of  the  stomach  and 
the  diaphragm,  and  in  the  line  of  the  axilla  extends  from  the  eighth  to  the 
eleventh  rib."  Its  shape  is  that  of  a  compressed  oval  having  three  surfaces. 
"Of  these,  one,  the  external  and  posterior,  is  large  and  convex,  fitting 
against  the  commencement  of  the  arch  of  the  diaphragm  and  looking  upwards, 
backwards,  and  to  the  left.  A  second,  the  narrowest,  is  placed  vertically,  and 
looks  directly  inwards,  being  applied  to  the  outer  border  of  the  left  kidney; 
whilst  the  third  surface,  which  is  separated  from  the  last  described  by  a  distinct 
vertical  ridge,  is  larger  than  it  and  concave.  This  surface  is  applied  to  the 
great  cul-de-sac  of  the  stomach  and  is  in  contact  also  with  the  tail  of  the  pancreas 
and  with  the  extremity  of  the  arch  of  the  colon  (splenic  flexure).  Near  the 
ridge  above  mentioned  there  is  a  vertical  fissure  in  the  anterior  surface,  at  the 
part  where  the  vessels  and  nerves  enter  the  organ;  this  part  is  termed  the  hilus" 
(Quain).  The  spleen  is  held  in  place  by  means  of  reduplications  of  perito- 
neum. Such  are  the  gastro-splenic,  pancreatico-splenic,  and  phreno-splenic 
ligaments.  Occasionally  there  is  a  colo-reno-splenic  ligament  at  the  lower 
extremity  of  the  spleen  (Villar).  The  splenic  blood  vessels  are  contained 
in  the  gastro-splenic  omentum.  The  splenic  artery,  after  giving  off  the  gastro- 
epiplocia  sinistra,  breaks  up  into  a  number  of  branches,  a  few  of  which — the 
vasa  brevia — turn  back  to  the  stomach.  The  remaining  branches  enter  the 
spleen  at  the  hilus.  The  splenic  vein,  in  its  origin,  corresponds  to  the  artery. 
It  is  a  large  vessel  and  lies  below  the  artery.  In  its  subsequent  course  it  is 
situated  behind  the  pancreas. 

Splenopexy. — Splenopexy  is  performed  for  the  cure  of  "floating  spleen." 
Several  methods  have  been  devised  to  anchor  the  spleen  in  the  left  hypochon- 
drium. 

(A)  Rydygier's  Method. — Freely  open  the  belly  in  the  middle  line.  Locate 
the  spleen.  Between  the  ninth  and  tenth  ribs  make  a  transverse  incision 
through  the  parietal  peritoneum  (Fig.  532).  Introduce  the  fingers  through 
this  incision  and  separate  the  peritoneum,  below  the  incision,  from  the  parietes, 
and  thus  form  a  pocket  whose  mouth  is  directed  upwards  (A,  A,  Fig.  533). 
The  pouch  is  made  sufl&ciently  large  to  receive  the  lower  end  of  the  spleen. 
If  the  spleen  (B)  is  placed  in  this  pouch,  its  weight  may  enlarge  it  so  that  the 
operation  is  rendered  useless.     To  prevent  this,  insert  a  few  catgut  sutures 

440 


SPLENOPEXY. 


441 


through  the  peritoneum  and  part  of  the  parietes  immediately  below  the  lower 
limit  of  the  pouch.  These  will  prevent  further  separation  of  the  peritoneal 
flap  from  the  parietes.  Place  the  lower  end  of  the  spleen  in  the  pouch.  Unite 
the  free  edge  of  the  peritoneal  flap,  forming  the  pouch,  to  the  gastro-splenic 
ligament  by  one  or  more  sutures.  If  it  seems  desirable,  suture  the  spleen 
itself  to  the  peritoneal  incision,  or  form,  from  the  peritoneum  above,  a  flap 
with  its  base  next  the  spleen;  reflect  this  flap  over  the  spleen  and  suture  it  to 
the  gastro-splenic  ligament. 

(B)  Bardenheuer's  Method. — Place  the  patient  on  his  right  side.     Make  an 
incision  in  the  axillary  line,  from  the  tenth  rib  to  the  iliac  crest.     At  the  level  of 


Fig.  532. 


Fig.  533. 


Figs.  532  and  533. — {Monod  and  Vanverts.) 

the  tenth  rib  make  an  incision  at  right  angles  to  the  first.  Divide  the  soft  parts 
down  to  the  peritoneum.  Make  an  opening  through  the  peritoneum  of  size 
suflScient  to  permit  of  exploration  and  of  the  passage  of  the  spleen  through  it. 
Have  an  assistant,  with  his  hand  on  the  belly-wall,  push  the  spleen  towards 
the  wound.  Bring  the  spleen  out  through  the  peritoneal  wound.  With 
sutures  diminish  the  size  of  the  peritoneal  wound  and  unite  it  to  the  splenic 
pedicle.  Pass  one  stout  suture  through  the  lower  end  of  the  spleen  and  tie 
it  around  the  tenth  rib.  Close  the  wound  in  the  soft  parts.  The  spleen  now 
lies  with  its  inferior  pole  in  a  retroperitoneal  pouch;  its  pedicle  is  fixed  to  the 
peritoneal  wound,  and  its  body  is  suspended  from  the  tenth  rib. 

The  foregoing  operations  are  so  recent  that  their  merits  have  not  been 
fully  tested;  probably  Bardenheuer's  is  the  safer  and  easier. 

Splenectomy. — The  spleen  may  be  removed  for  the  following  conditions 
(Greig  Smith): 

I.  Injury  or  prolapse. 


442  THE    SPLEEN. 

2.  Certain  cases  of  movable  spleen. 

3.  Simple  hypertrophy,  with  or  without  cirrhosis. 

4.  Sarcoma  or  lympho-sarcoma  in  the  early  stages. 

5.  Cysts. 

6.  Hydatid  disease. 

In  cases  of  leucocythtemia  the  spleen  ought  never  to  be  removed. 

In  early  cases  of  splenic  anaemia  without  hepatic  cirrhosis,  splenectomy 
gives  good  results. 

Jonnesco  recommends  the  following  method  of  operating:  The  surgeon 
should  stand  at  the  patient's  right  side,  because  from  this  side  he  obtains  a 
better  view  of  the  pedicle,  the  ligation  of  which  is  the  most  important  step 
in  the  operation. 

Step  I. — Make  an  incision  in  the  linea  alba  from  the  ensiform  cartilage  down 
to  or  below  the  umbilicus. 

Step  2. — Isolation  of  the  spleen.  This  step  is  usually  easy,  but  it  may  be 
very  difficult  or  impossible.  Adhesions  may  be  so  extensive  and  firm  that 
the  spleen  may  be  practically  fused  to  its  own  bed  or  the  parietes.  Extensive 
and  firm  adhesions  may  be  a  contraindication  to  continuing  the  operation. 
When  the  adhesions,  though  intimate,  are  destructible,  the  operation  may  be 
continued,  but  in  separating  them  one  must,  where  necessary,  injury  the  ab- 
dominal wall  or  even  the  diaphragm  rather  than  the  spleen  itself.  All  adhesions 
which  may  contain  blood-vessels  must  be  doubly  ligated  before  division. 
When  the  phreno-splenic  ligament  is  vascular,  it  must  be  separated  into  several 
bands,  each  of  which  is  doubly  tied  and  divided.  To  reach  and  examine  this 
ligament  the  following  manoeuvre  is  essential.  The  operator,  covering  the 
•spleen  with  a  gauze  pad,  pulls  it  to  the  right,  while  an  assistant  draws  the  left 
lip  of  the  wound  to  the  left;  this  exposes  the  bed  of  the  spleen  and  the  dia- 
phragmatic vault.  Having  divided  the  phreno-splenic  ligament,  the  adhesions 
of  the  spleen  to  its  bed  are  next  attacked.  Often  adhesions  to  neighboring 
organs  require  division.  Once  the  adhesions,  both  normal  and  abnormal, 
have  been  separated,  it  is  easy  to  enucleate  the  organ,  beginning  with  its  lower 
extremity. 

Step  2,.— Section  of  the  pedicle.  When  delivered  from  the  belly  cavity 
the  spleen  is  turned  over  to  the  left  so  as  better  to  expose  the  internal  surface 
and  its  pedicle.  Division  of  the  pedicle  ought  to  be  accomplished  by  separating 
and  dividing  between  two  ligatures,  each  vessel  in  turn,  from  the  lower  side  up- 
wards. The  separation  of  each  vessel  is  one  of  the  most  delicate  steps  in  the 
operation.  One  must  avoid:  (a)  Too  great  traction  on  the  pedicle.  This  is 
done  by  an  assistant  supporting  the  spleen  and  preventing  its  sudden  displace- 
ment, (b)  Rupture  of  a  vessel  while  separating  it.  To  prevent  this  accident, 
use  the  fingers,  instead  of  instruments,  for  the  separation  of  vessels  or 
groups  of  vessels  (the  isolation  of  single  vessels  is  often  impossible).  The 
isolation  ai'^d  ligation  of  the  splenic  artery  (often  as  large  as  the  femoral)  and 
of  the  vein,  which  often  accompanies  it,  are  rendered  specially  difficult  because 


SPLENECTOMY, 


443 


of  the  tail  of  the  pancreas,  to  which  they  are  often  adherent.  WTien  this  is 
the  case,  it  is  best  to  throw  two  strong  ligatures  around  these  structures,  ligate 
en  masse,  cut  between  the  ligatures,  and  then  apply  individual  ligatures. 

Step  4. — Revision  of  splenic  bed  and  final  heniostasis:  Examine  the  whole 
bed  from  which  the  spleen  has  been  removed  and  stop  any  bleeding.  Retract 
the  stomach  and  intestines  to  the  right  and  examine  the  pillar  of  the  diaphragm. 
Here  there  is  often  to  be  found  a  bleeding  point  which  may  be  secured  by  a 
few  stitches  uniting  the  peritoneum  over  it. 


Fig.  534. — {Mayo.^ 


Step  5. — Close  the  abdomen.     The  dressings  applied  should  be  compressive 
and  elastic,  so  as  to  fill  up  the  void  left  by  the  removal  of  a  large  spleen. 
Contraindications  usually  given  and  Jonnesco's  opinion  thereof: 

(a)  Cachexia:  This  will  undoubtedly  remain  a  contraindication,  but  it 
is  difficult  to  define  the  limits  of  this  contraindication.  Cases  with  marked 
cachexia  have  been  greatly  improved  by  operation. 

(b)  Adhesions:  The  presence  of  adhesions  may  constitute  a  contraindi- 
cation. When  it  seems  possible  to  separate  the  adhesions,  the  surgeon  must 
consider:  (i)  The  general  condition  of  the  patient,  as  to  his  powers  of  enduring 
a  long  and  laborious  operation;  (2)  the  quantity  of  ascites  taken  as  an  index 


444  THE    SPLEEN. 

of  the  alterations  present  in  the  organs  of  the  belly;  (3)  the  friability  of  the 
splenic  tissues;  this  is  a  continual  menace  while  adhesions  are  being  separated. 

(c)  Size  and  weight  of  the  spleen :  There  is  no  real  contraindication,  Jon- 
nesco  has  operated  successfully  in  patients  from  twelve  to  sixty  years,  some 
having  enormous  hypertrophies. 

{d)  LeucocythcBinia  is  always  an  absolute  contraindication. 

In  Banti's  disease  (splenic  anaemia)  Mayo  has  found  partial  or  complete 
splenectomy  useful.  After  exposing  and  pulling  the  spleen  forwards  out  of 
its  bed,  using  blunt  dissection  to  form  a  passage-way  around  the  pedicle, 
grasp  the  pedicle  with  the  blades  of  a  suitable  clamp  (gastro-enterostomy. 
clamp  with  blades  protected  by  rubber  tubing).  Complete  the  separation  of 
the  spleen  from  its  connections  and  deliver  it  through  the  abdominal  wound. 
The  forceps  on  the  pedicle  should  be  placed  as  far  away  from  the  spleen  as 
possible  for  obvious  reasons  (Fig,  534).  If  partial  splenectomy  is  chosen,  cut 
away  as  much  of  the  organ  as  necessary  and  close  the  wound  with  a  contin- 
uous button-hole  suture  of  catgut  introduced  with  a  round  needle;  loosen  the 
clamp.  If  hemorrhage  occurs  temporarily  reapply  the  clamp  and  introduce 
more  sutures  where  they  will  do  most  good.  If  complete  splenectomy  is  chosen 
the  temporary  control  of  the  pedicle  makes  its  permanent  ligation  easy. 

Mayo  ("  Joum.  A.  M.  A,"  Jan.  i,  1910)  notes  that  "it  has  been  shown  ex- 
perimentally that  reduction  of  the  arterial  supply  by  ligation  results  in  atrophy 
of  the  spleen  and  that  as  long  as  the  veins  are  left  intact  necrosis  does  not  occur. 
If  the  splenic  artery  divides  in  the  hilum,  ligation  of  branches  would  appear 
to  be  an  active  competitor  of  partial  splenectomy. 


CHAPTER  XXXIX. 
THE  SUPRARENAL  BODIES. 

The  suprarenal  bodies  rest  upon  the  diaphragm  opposite  the  eleventh  and 
twelfth  ribs.  They  are  separated  from  one  another  by  an  interval  of  2  to  2  1/2 
inches.  They  are  situated  at  the  upper  and  inner  border  of  each  kidney, 
and  obtain  a  rich  supply  of  blood  through  special  arteries  from  the  aorta  and 
through  branches  of  the  renal  and  phrenic  arteries.  In  front  of  the  left  supra- 
renal lies  the  stomach;  to  its  outer  side  is  the  spleen.  The  right  suprarenal 
"is  related  in  front  to  both  the  inferior  and  posterior  surfaces  of  the  right  lobe 
of  the  liver  (impressio  suprarenalis) ;  internally  to  the  vena  cava,  vi^hich  slightly 
overlaps  it,  and  its  inferior  angle  is  crossed  by  the  first  bend  of  the  duodenum. 
It  lies  behind  the  foramen  of  Winslow."     (Woolsey.) 

Adrenalectomy. — The  surgery  of  the  suprarenal  bodies  belongs  more 
to  the  future  than  the  present  but  even  nov^  enough  has  been  done  to  demand 
a  short  notice  here. 

The  most  common  cause  of  Addison's  disease  is  tuberculosis  of  the  supra- 
renal body,  and  most  of  the  successful  operations  have  been  performed  in  such 
cases.  Usually  operation  has  been  undertaken  on  a  diagnosis  of  "retro- 
peritoneal tumor"  or  of  a  tumor  affecting  the  upper  pole  of  the  kidney,  and 
these  errors  in  diagnosis  are  liable  to  be  repeated  in  the  future.  An  early 
recognition  of  suprarenal  disease  is  impossible  in  our  present  state  of  knowledge 
or  ignorance. 

The  suprarenal  bodies  may  be  reached  through  the  lumbar  region  or  through 
the  peritoneum.  When  the  former  route  is  chosen,  the  incision  must  be  ex- 
tensive, and  exactly  like  that  for  nephrectomy.  In  most  cases  of  adrenalectomy, 
nephrectomy  will  be  part  of  the  operation,  for  two  reasons:  (a)  because  the 
removal  of  the  kidney  renders  less  difficult  an  atrociously  difficult  operation : 
(b)  because  the  kidney  if  often  involved  in  the  disease,  especially  if  that  disease 
is  malignant. 

Helferich  operated  through  the  lumbar  route  and  partially  removed  a 
tuberculous  suprarenal  with  complete  success  (Schede,  "Handbuchder  prak- 
tischen  Chir.,"  iii,  1106).  Most  operations  have  been  performed  by  the  trans- 
peritoneal route.  Oestreich  diagnosed  and  Hadra  operated  upon  a  pulsating 
tumor  of  the  suprarenal.  When  the  abdomen  was  opened  in  the  middle  line 
above  the  umbilicus,  a  tumor  the  size  of  a  hen's  egg,  of  a  whitish  and  yellowish- 
brown  color,  was  seen  through  the  lesser  omentum.  This  tumor  was  on  and 
to  the  left  of  the  aorta,  and  after  excision  proved  to  be  a  much  caseated 
suprarenal  body.  The  wound  was  packed  and  the  patient  recovered.  In  a 
case  operated  on  by  Jonas  (Schede,  loc.  cit.)  the  bronze  hue  so  characteristic  of 
Addison's  disease  faded  in  ten  days  and  disappeared  in  three  weeks.  There 
is  little  prospect  of  much  benefit  from  operation  on  malignant  tumors  of  the 
suprarenals. 

445 


CHAPTER  XL. 

OPERATIONS  UPON  THE  LIVER. 

OPERATIONS  FOR  HEPATOPTOSIS,  OR  T^TOBILE  OR 
FLOATING  LIVER. 

Ptosis  of  the  liver  may  be  partial  or  complete. 

Partial  ptosis  means  that  a  portion  of  the  liver  is  more  or  less  pushed 
away  or  snared  off  from  the  rest  of  the  organ  as  a  result  of  error  is  dress  (tight 
lacing)  or  of  some  disease.  Riedel's  tongue-shaped  lobe,  so  common  in  cho- 
lelithiasis, is  a  form  of  partial  ptosis.  Occasionally  the  junction  between  the 
aberrant  lobe  and  the  rest  of  the  liver  is  thin,  and  from  irritation,  etc.,  has 
become  sclerosed. 

Complete  ptosis  means  that  the  liver  is  dislocated  en  masse  to  a  greater 
or  less  degree. 

(A)  Operations  for  Partial  Hepatoptosis. — i.  Indirect  Operations. — 
When  the  ptosis  is  in  the  form  of  a  Riedel  lobe  and  dependent  on  gall-bladder 
disease,  the  latter  disease  must  be  treated  according  to  the  methods  advised  in 
the  chapter  on  Biliary  Surgery.     Excellent  results  are  thus  obtained. 

2.  Excision. — The  mobile  lobe  may  be  excised.     (See  "Hepatectomy.") 

3.  VentrO'Jixation. — Open  the  al:)domen  over  the  most  prominent  part  of 
the  tumor.  Suture  the  "floating  lobe"  to  the  parietes  by  several  thick  catgut 
sutures.     Before  tying  the  sutures  scarify  the  surfaces  about  to  be  opposed. 

4.  Ke/ir's  Operation. — Kehr,  adopting  Rydygier's  idea  in  splenopexy, 
applies  it  to  the  fixation  of  partial  hepatoptosis.  Make  a  horseshoe-shaped 
incision  (concavity  upwards)  around  the  lower  circumference  of  the  mobile 
lobe  down  to  but  not  through  the  transversalis  fascia.  At  the  lowest  point 
in  the  wound  open  the  belly  by  a  transverse  incision  through  the  transversalis 
fascia  and  the  peritoneum.  Separate  the  transversalis  fascia  and  the  perit- 
oneum, together,  from  the  more  superficial  structures  of  the  parietes  over  an 
area  corresponding  to  the  horseshoe-shaped  incision.  At  the  upper  end  of 
this  loosened  area  make  an  incision  through  the  fascia  and  peritoneum  parallel 
to  the  lower  transverse  incision.  A  pocket  of  fascia  and  peritoneum  is  thus 
formed  into  which  the  "floating  lobe"  or  its  lower  margin  may  be  tucked  and 
secured.     Close  the  wound  with  sutures. 

(B)  Operations  for  Complete  Hepatoptosis. — (I)  Step  i. — Exposure 
of  organ:  This  may  be  accomplished  by  a  vertical  incision  either  in  the  middle 
line  or  along  the  external  border  of  the  right  rectus  muscle  or  by  a  cut  paral- 
lel to  the  costal  arch.  The  vertical  incisions  are  the  better,  and  may  be  supple- 
mented by  a  transverse  cut  if  such  appears  necessary. 

446 


HEPATOPEXY. 


447 


Step  2. — Return  the  liver  to  its  normal  position.  If  the  organ  has  become 
adherent  in  its  faulty  location,  and  adhesions  must  be  separated,  unless,  of 
course,  they  are  so  extensive  that  the  danger  involved  in  their  separation  would 
be  out  of  proportion  to  the  good  to  be  attained  by  a  successful  hepatopexy. 
An  assistant  supports  the  liver  in  its  improved  position  while  the  surgeon 
carries  out  the  next  step. 

Step  3. — Fixation  oj  the  liver  by  sutures:  Pass  coarse  catgut  or  silk  sutures 
through  the  parenchyma  of  the  anterior  edge  of  the  liver,  each  suture  taking 
a  deep  hold  of  the  organ,  and  then  make  the  sutures  penetrate  between  the 
cartilages  of  the  adjacent  ribs.  During  this  procedure  the  pleura  has  been 
injured,  but  no  harm  has  resulted.  The  sutures  must  be  thick  to  avoid  cutting 
the  friable  organ.  In  actual  practice  the  number  of  sutures  has  varied  from 
two  to  eight;  the  more  numerous  they  are,  the  more  is  the  strain  divided  and 
the  liability  to  cut  lessened.  The  hepatic  and  parietal  surfaces  which  are  to 
be  opposed  should  be  scarified  before  the  sutures  are  tied.  Care  must  be 
taken,  when  the  sutures  are  being  tied,  to  avoid  cutting  the  liver  substances 
with  the  threads.  Some  surgeons  apply  a  few  sutures  between  the  liver  and 
the  upper  end  of  the  abdominal  wound.  Lucas  Championniere  modifies  the 
operation  by  passing  some  of  the  threads  through  the  suspensory  ligament. 

If  it  is  impossible  to  reduce  the  liver,  it  may  be  fixed  by  suture  wherever 
possible  so  as  to  give  relief  from  distressing  symptoms. 

(II)  Depage's  Operation  {Hepatopexy  and  Laparectomy). — Depage  considers 
laxity  of  the  abdominal  walls  a  great  factor  in  the  production  of  hepatoptosis 
and  directs  his  attention  specially  towards  removal  of  this  condition. 


Fig. 


53  5- 


M oiuvl  and  Wutverls.) 


Fig.   536. —  [Mouod  and  ]'unverts.) 


Step  I. — Make  the  horizontal  incision  A  B  (Fig.  535)  from  the  tip  of  the 
eleventh  rib  on  one  side  to  the  tip  of  the  eleventh  rib  on  the  other  side.  From 
the  point  A  make  an  incision  A  C,  downwards  and  inwards  to  meet  an  imaginar)- 
line  passing  horizontally  through  the  umbilicus.  The  length  of  the  cut  A  C 
is  equal  to  one-half  the  cut  A  B.  From  the  point  B  make  the  incision  B  D  in 
the  same  way  as  A  C  was  made.  From  the  points  C  and  D  make  curved  inci- 
sions downwards  to  near  the  pubis.  The  convexity  of  the  curves  is  outwards. 
These  cuts  meet  at  the  point  E.  Remove  all  the  skin  enclosed  by  the  above 
incisions.  Dilatation  of  the  belly  has  caused  the  linea  alba  to  become  very 
wde.     "'Remove  the  linea  alba,  including  the  peritoneum,  from  the  anterior 


448  OPERATIONS   UPON   THE    LIVER. 

or  internal  border  of  one  rectus  muscle  to  the  internal  borders  of  the  other 
rectus  muscle.  Make  traction  upon  the  umbilical  ligament  of  the  liver  and 
the  inferior  extremity  of  the  falciform  ligament,  and,  pulling  them  into  the 
upper  angle  of  the  wound,  shorten  and  anchor  them  there  by  sutures." 

Step  2. — Suture  the  abdominal  wound  with  extreme  care.  Depage  sutures 
in  planes  as  follows:  (a)  The  peritoneum  alone;  (6)  the  peritoneum  and  mus- 
cular planes  together;  (c)  the  muscular  plane  alone;  {d)  the  aponeurotic  and 
muscular  planes  together;  {e)  the  aponeurosis  alone;  (/)  the  skin  and  sub- 
cutaneous tissue  together;  (g)  the  skin  alone.  In  suturing,  the  edge  of  the 
wound  A  C  is  united  to  the  edge  A  F;  the  edge  B  D  to  B  F,  and  the  edge 
C  E  to  the  edge  D  E.     The  resultant  scar  is  T-shaped  (Fig.  536). 

HEPATECTOMY.     EXCISION  OF  HEPATIC  TUMORS,  ETC. 

As  it  is  self-evident  that  the  liver  can  never  be  removed  in  Mo,  it  is  useless 
to  prefix  the  word  partial  to  the  title  of  this  section. 

The  experiments  of  Ponfick,  repeated  and  supported  by  other  observers, 
have  proved  that  much  liver  tissue  can  be  removed  without  specific  injury 
(three-fourths  was  removed  in  animals) ,  and  that  new  liver  tissue  is  formed  to 
take  the  place  of  that  removed.  The  great  impediment  to  hepatic  surgery 
has  been  the  fear  of  hemorrhage.  Many  methods  have  been  adopted  to  over- 
come this  real  danger.     A  few  of  the  methods  will  be  described. 

I.  Exposure  of  the  Tumor. — The  abdomen  is  opened  over  the  tumor  by  a 
cut  made  in  any  direction  which  may  be  convenient  or  by  a  combination  of 
cuts.  The  incision  must  be  large  enough  to  give  very  free  access  to  the  field 
of  operation.  The  tumor  is  now  examined  as  to  kind  and  location.  It 
is  assumed  that  the  diagnosis  is  such  that  radical  operation  is  permissible. 
If  the  tumor  involves  most  of  the  right  lobe  of  the  liver,  the  operaton  must  be 
at  once  abandoned,  so  also  if  the  hilus  is  much  involved.  Tumors  on  the  pos- 
terior and  superior  parts  of  the  liver  are  inaccessible.  Tumors  of  the  left 
lobe  and  of  the  anterior  margin  of  the  organ  may  be  brought  forwards  by 
division  of  parts  of  the  hepatic  ligaments;  this  permits  of  partial  dislocation 
of  the  whole  organ.  Some  surgeons  have  excised  the  lower  ribs  (subperios- 
teally)  and  have  thus  been  enabled  to  retract  the  diaphragm  upwards.  When 
the  patient  is  lying  on  his  back  with  the  posterior  hepatic  region  supported  on  a 
sand-bag,  it  is  extraordinary  how  much  of  the  liver  may  be  brought  out  through 
the  Mayo-Robson  incision  (page  455)  without  any  resection  of  ribs.  It  is 
difiicult  to  believe  that  enough  benefit  can  be  attained  by  rib  resection  to  war- 
rant the  extra  trauma  and  risk. 

II.  Removal  of  the  Tumor. — When  peritoneum  exists  over  the  tumor  and 
is  free  from  disease,  it  should  be  divided  and  reflected  from  the  surface  of  the 
tumor.  If  the  tumor  is  non-malignant  and  appears  to  be  fairly  well  encap- 
sulated, it  may  often  be  shelled  out  of  its  hepatic  bed  with  but  little  hemorrhage. 
When  the  tumor  is  very  small  and  situated  at  the  liver  margin,  it  may  be  re- 


HEPATECTOMY.  449 

moved  by  a  V-spaped  incision  made  with  knife,  scissors,  or  thermocautery. 
While  the  cut  is  being  made  an  assistant  compressing  the  neighboring  liver 
controls  bleeding  temporarily.  When  the  tumor  is  attached  to  the  liver  by 
a  distinct  pedicle,  the  pedicle  may  be  surromided  by  an  elastic  ligature  and 
the  tumor  removed,  or  the  removal  may  be  accomplished  without  the  aid  of 
the  elastic  constrictor.  In  aU  the  above  instances  bleeding  is  temporarily 
controlled  while  the  tumor  is  bein^  removed.  When  the  tumor  is  non-en- 
capsulated, non-pedunculated,  or  involves  much  of  the  liver  substance,  one 
requires  to  proceed  step  by  step,  stopping  bleeding  as  one  goes. 
Methods  of  Hemosta§is. — I.  During  the  operation: 

(a)  Temporary  elastic  ligature:  A  rubber  tube  thrown  around  a  pedicle 
permits  the  surgeon  to  remove  the  tumor  at  his  leisure  and  subsequently 
take  other  means  to  stop  the  bleeding  permanently.  When  there  is  no  pedicle, 
it  has  been  advised  to  pierce  the  whole  thickness  of  the  hver  behind  the  tumor 
with  a  cannula,  place  a  double  elastic  ligature  through  the  instrument,  and  tie 
the  ends  of  the  ligature  on  each  side  of  the  tumor  so  as  to  act  as  a  tourniquet. 

(b)  Auvray  recommends  applying  to  the  liver  around  the  portion  to  be 
removed  a  series  of  interlocked  ligatures  of  thick  silk  or  catgut.  To  apply 
the  ligatures  use  a  blunt  pedicle  needle  vvdth  a  very  long  curve.  Each  indi- 
vidual ligature,  after  being  crossed  with  its  fellow  to  the  right  and  left,  is  slowly 
and  steadily  tied  with  such  firmness  that  the  liver  parenchyma  is  cut,  but 
the  vessels  remain  undivided  in  the  loop.  When  the  whole  series  of  ligatures 
is  tied,  the  tumor  is  removed  with  cautery,  knife,  or  scissors.  It  is  of  impor- 
tance while  transfixing  the  liver  with  the  needle  to  use  little  force,  and  when 
any  obstacle  to  the  passage  of  the  instrument  is  encountered,  to  manipulate 
the  needle  from  side  to  side  and  so  gently  guide  it  past  the  obstruction.  Such 
obstructions  are  usually  large  vessels,  and  any  force  used  might  injure  them. 
The  points  of  transfixion  should  be  about  one  centimeter  (3/8  inch)  apart. 
Auvray's  researches  have  been  very  thorough  and  successful.  The  method 
he  advises  certainly  appeals  to  one's  common  sense. 

Using  practically  the  same  method  as  Auvray,  Cull  en  has  removed  a  large 
carcinoma  of  the  liver.  After  the  ligatures  were  in  place  he  found  that  the 
"raw  surface  could  be  rolled  in  upon  itself,  so  that  the  two  halves  formed  flaps. 
These  were  brought  together  until  little  or  no  raw  surface  remained.  The 
ends  of  the  sutures  that  had  already  been  tied  were  utilized  to  bring  the  opposite 
sides  together." 

Freeman  has  used  with  success,  for  the  same  purpose  and  in  similar  maimer 
narrow  strips  of  gauze.  He  found  much  difficulty  in  removing  the  gauze 
because  the  knots  sank  into  the  liver  substance,  so  he  now  recommends  that 
the  ends  of  gauze  be  fastened  with  forceps  or  catgut  instead  of  being  knotted. 
("Trans.  Am.  Surg.  Assoc,"  1904.) 

Auschiitz  ("Deutschen  Gesellsch.  fur  Chir.,"  1907)  lays  down  the  fol- 
lowing rules  for  resection  of  the  liver: 

I.  The  incision  "through  the  liver  substance  should  be  made  with  a  sharp 
29 


45©  OPERATIONS    UPON   THE   LIVER. 

knife  and  the  vessels  picked  up  with  forceps  and  ligated.  If  the  hepatic  tissue 
is  divided  by  blunt  force  the  vessels  subsequently  retract  and  are  difficult 
to  find  and  secure. 

2.  When  possible  the  liver  wound  should  be  wedge-shaped  to  permit  closure 
with  suture. 

3.  No  special  instruments  are  required  for  the  insertion  of  deep  ligatures 
in  the  liver.     The  ligatures  should  be  tied  slowly  but  firmly. 

4.  In  suitable  cases  the  temporary  use  of  an  elastic  ligature  is  valuable. 

5.  Usually  no  abdominal  tampon  is  required  after  suture. 

6.  Division  of  the  hepatic  ligaments  is  often  an  aid  in  resection. 

7.  When  it  is  necessary  to  attack  the  dome  of  the  liver,  do  not  hesitate  to 
resect  the  right  costal  arch  and  to  divide  the  suspensory  ligament. 

Garre  uses  catgut  No.  2  for  deep  sutures  which  go  through  the  whole  thick- 
ness of  the  liver,  while  for  serous  sutures  and  for  the  ligation  of  individual 
vessels  on  the  cut  surface  of  the  liver  he  uses  extremely  fine  silk.  He  does  not 
treat  the  stump  extraperitoneally,  has  not  lost  a  single  case  and  has  penetrated 
the  liver  substance  to  the  extent  of  fully  5  inches  (10  to  14  cm.). 

(c)  Thermocautery:  Many  surgeons  use  the  thermocautery  instead  of  the 
knife  when  dividing  liver.  While  the  cautery  does  not  control  bleeding  from 
the  larger  vessels,  it  certainly  does  control  oozing.  The  cautery  ought  always 
to  be  ready  when  hepatic  incisions  are  made,  since  it  may  be  found  useful, 
at  least  as  an  aid  to  other  methods. 

{d)  Ligature:  The  ligation  of  hepatic  vessels  is  often  difficult,  their  walls 
being  thin  and  delicate.  Frequently  direct  ligation  of  the  vessels  is  impossible. 
When  this  is  the  case,  one  may,  with  a  curved  needle,  pass  a  suture  around 
the  vessel,  and  on  gently  tying  it  the  bleeding  ceases.  To  this  suture-ligature 
the  Germans  give  the  name  "Umstechung." 

The  above  are  the  principal  means  of  hemostasis  used  during  the  operation. 

II.  The  methods  of  securing  hemostasis  after  the  operation  are  practically 
the  same  as  the  methods  of  treating  the  stump. 

(A)  Intraperitoneal. — The  liver  wound,  having  been  closed  by  suture  or 
ligature,  or  charred  by  the  thermocautery,  is  allowed  to  drop  back  in  the  belly. 
If  peritoneal  flaps  were  dissected  back  from  over  the  tumor,  they  are  replaced 
and  sutured  together.  Place  a  strip  of  gauze  under  the  liver  and  against 
the  liver  wound;  bring  the  end  of  this  strip  out  through  the  abdominal  wound. 
Close  the  excess  of  wound. 

(B)  Extraperitoneal. — The  tumor  is  delivered  through  the  abdominal  wall. 
The  pedicle  is  compressed  by  an  elastic  ligature.  The  tumor  is  cut  away. 
The  stump  is  fixed  to  the  abdominal  wall  by  sutures  or  by  pedicle  pins.  The 
elastic  ligature  is  left  in  situ.  The  dangers  of  this  method  are.  first,  that  the 
sutures  or  pins  fixing  the  liver  to  the  abdominal  wall  are  very  liable  to  cut 
through  the  friable  liver  substance;  and,  second,  that  the  risks  of  infection 
through  the  stump  are  very  real.  Some  surgeons  have  performed  the  oper- 
ation in  two  stages.     At  the  first  sitting  the  liver  is  attached  to  the  belly-wall. 


ABSCESS    OF    LIVER.  45 1 

Only  after  adhesions  have  formed  is  the  tumor  removed.  When  applicable, 
this  may  be  a  good  method. 

(C)  The  pedicle  is  treated  as  in  A,  but  the  liver  wound  is  walled  off  from 
the  rest  of  the  peritoneal  cavity  by  means  of  gauze  packs  and  a  tampon  of 
gauze  is  pressed  against  the  wound  itself.  The  ends  of  the  pieces  of  gauze 
used  for  pack  and  tampon  are  brought  out  through  the  abdominal  wound. 

Undoubtedly  the  best  way  to  treat  the  stump  where  possible  is  by  a  com- 
bination of  suture  and  packing.  The  surface  of  the  pack  facing  the  ab- 
dominal cavity  should  be  covered  by  rubber  tissue.  The  ends  of  the  catgut 
sutures  applied  to  the  liver  should  be  left 
long  and  tied  over  the  pack  so  as  to  keep  the 
latter  in  place.     (See  "Cholecystectomy.") 

To  exert  hemostatic  pressure  upon  the 
liver  and  to  prevent  the  cutting  of  the 
parenchyma    by    sutures  one   rubber  tube  Fig.  537. 

may  be  laid  on  the  upper  surface  of  the 

liver,  another  on  the  lower  surface.  Thick  catgut  sutures  (A,  B,  Fig.  537) 
penetrating  the  liver  are  fastened  to  the  tubes.  The  ends  of  the  tubes  are 
brought  out  of  the  wound  and  are  to  be  removed  when  they  have  served  their 
purpose.  Instead  of  rubber  tubes,  plates  of  decalcified  bone  and  of  various 
materials  have  been  employed. 

Kocher  has  applied  his  large  stomach  clamp  to  the  liver  with  force,  crush- 
ing through  the  parenchyma  and  excising  the  portion  of  liver  distal  to  the 
clamp.     He  leaves  the  clamp  in  situ  for  forty-eight  hours. 

Van  Buren  Knott  has  successfully  removed  a  primary  sarcoma  from  the 
anterior  border  of  the  liver  (the  tumor  was  pedunculated  and  weighed  over 
one  pound)  using  rubber-covered  clamps  which  he  left  in  situ.  The  opera- 
tion was  difiicult  because  of  adhesions  and  the  patient  was  much  debilitated. 

ABSCESS  OF  THE  LIVER. 

Aspiration. — Aspiration  as  a  method  of  treatment  for  liver  abscess  is  not 
to  be  recommended.  It  has  its  sphere  of  usefulness  as  a  means  of  diagnosis, 
but  its  use  is  not  without  danger. 

The  skin  is  cleaned  over  the  most  prominent  or  most  tender  part  of  the 
swelling,  usually  the  ninth  or  tenth  interspace  vertically  below  the  angle  of 
the  scapula,  and  the  sterilized  aspirating  needle  is  inserted  in  various  direc- 
tions until  pus  is  found.  Greig  Smith  remarks  that  "the  movements  of  the 
needle,  following  the  movements  of  the  liver  (if  it  moves  with  respiration), 
must  not  be  checked,  as  thereby  the  liver  tissue  may  be  torn  and  permit  escape 
of  pus  into  the  peritoneum." 

Hepatotomy. — (A)  Abdominal  Route. — The  object  of  operation  is  to  expose 
the  enlarged  liver;  to  examine  it;  to  incise  and  evacuate  the  contained  pus 
without  soiling  the  general  peritoneal  cavity.  An  incision  four  to  five  inches 
in  length  is  made  over  the  most  prominent  part  of  the  swelling.     This  incision 


452  OPERATIONS    UPON    THE    LIVER. 

is  usually  longitudinal.  The  belly  is  opened  and  the  liver  examined.  If  the 
liver  is  found  adherent  to  the  parietes  opposite  the  wound  these  adhesions 
ought  to  be  preserved,  as  the  avoidance  of  peritoneal  contamination  is  ren- 
dered easier  by  their  presence.  When  a  sufficiency  of  adhesions  is  not  pres- 
ent, the  portion  of  liver  about  to  be  attacked  is  carefully  isolated  from  the 
peritoneum  by  pads  of  gauze.  Unless  the  exact  location  of  the  abscess  is 
very  evident,  an  aspirating  needle  is  passed  into  the  liver  until  pus  is  found. 
The  needle  being  held  in  place,  a  knife  or  the  blade  of  a  cautery  is  inserted 
into  the  abscess,  guided  by  being  kept  in  contact  with  the  needle.  The  needle 
is  withdrawn.  The  forefinger  is  pushed  into  the  abscess  along  the  side  of  the 
knife,  which  is  now  taken  out.  The  abscess  cavity  is  explored  digitally  and 
any  signs  of  a  second  abscess  noted.  If  such  exists,  it  may  be  opened  from 
the  first  cavity  by  the  finger  or  a  closed  hemostat  being  pushed  into  it.  The 
abscess  cavity  is  now  carefully  douched  with  hot  water,  a  rubber  drainage- 
tube  is  inserted  to  its  deepest  part,  and  the  rest  of  the  cavity  loosely  filled  with 
mUdly  iodoformized  gauze.  The  pads  of  gauze  which  have  protected  the 
peritoneal  cavity  are  removed  and  the  neighboring  peritoneum  is  mopped 
clean  and  dry.  Smith  recommends  that  the  whole  length  of  the  incision  in 
the  liver  be  sutured  to  the  abdominal  wound.  This  may  be  done  with  very 
coarse  catgut  or  silk  sutures.  Coarse  sutures  are  necessary,  as  fine  ones 
would  cut  through  the  liver  substance.  Any  of  the  abdominal  wound  un- 
occupied by  attached  liver  is  closed  by  sutures.  Abundant  absorbent  dress- 
ings are  applied  and  the  patient  put  to  bed. 

According  to  the  amount  of  discharge  the  wound  will  require  dressing  at 
more  or  less  frequent  intervals.  The  outer  dressings,  i.  e.,  those  down  to  the 
drainage-tube,  will  probably  require  to  be  changed  in  a  few  hours.  Unless 
demanded  by  the  condition  of  the  patient,  the  packing  of  iodoform  gauze  filling 
the  abscess  cavity  ought  not  to  be  changed  before  twenty-four  or, forty-eight 
hours  after  operation.  When  the  packing  is  withdrawn,  if  necessary,  the 
abscess  cavity  may  be  gently  douched  with  hot  water.  This  is  best  accom- 
plished by  attaching  a  soft-rubber  catheter  to  the  tube  of  an  irrigator  and  pass- 
ing it  into  the  deepest  part  of  the  cavity.  Thorough  and  gentle  lavage  is  thus 
insured.  The  irrigator  ought  not  to  be  elevated  much  more  than  two  feet. 
After  washing,  the  cavity  is  once  more  loosely  filled  with  mildly  iodoformized 
gauze  and  the  dressings  applied.  In  all  such  cases  iodoform  is  better  than 
plain  gauze,  but  the  iodoform  ought  to  be  in  small  quantity,  as  absorption  is 
liable  to  be  great  in  such  an  organ  as  the  liver. 

(B)  Transpleural  or  Thoracic  Route. — When  the  abscess  is  situated  far 
back  on  the  dorsum  of  the  liver,  evacuation  by  the  abdominal  route  is  inap- 
plicable. By  the  time  that  a  hepatic  abscess  has  become  large  enough  to  be 
diagnosed  and  its  position  ascertained,  there  is  almost  always  adhesive  pleuritis 
present;  the  liver  is  adherent  to  the  diaphragm,  and  the  diapdragmatic  pleura 
to  the  parietal,  so  that  a  safe  route  exists  to  the  pus  via  the  obliterated  portion 
of  the  pleural  cavity. 


SUBPHRENIC   ABSCESS.  453 

The  Operation. — Place  the  patient  on  his  sound  side.  Demonstrate  the 
presence  and  location  of  the  pus  by  the  aspirating  needle  introduced  through 
the  ninth  or  tenth  intercostal  space  vertically  below  the  angle  of  the  scapula. 
Make  an  incision  about  three  or  four  inches  in  length  along  the  rib  immediately 
below  the  aspirating  needle.  Excise  about  two  inches  of  this  rib,  subperi- 
osteally.  As  a  rule,  the  site  of  the  excised  rib  is  below  the  pleura  or  this  portion 
of  pleuja  is  obliterated.  If  the  pleural  cavity  is  opened  by  accident  or  design, 
it  must  be  at  once  protected  (a)  by  the  insertion  of  a  few  catgut  stitches  to  close 
the  cavity,  {h)  by  applying  a  pack  of  gauze.  This  gauze  pack  may  well  be 
held  in  place  by  a  few  stitches  of  fine  plain  catgut.  By  the  time  it  is  safe  to 
remove  the  gauze  the  catgut  will  have  been  absorbed.  The  diaphragm  lies 
exposed;  seize  it  with  forceps  and  mcise  it.  This  exposes  the  liver,  usually 
adherent  to  the  diaphragm.  The  aspirating  needle  still  in  situ  forms  a  guide 
to  the  abscess,  which  must  be  evacuated  as  described  in  the  preceding 
paragraphs. 

Choice  of  Operation. — Many  surgeons  consider  the  thoracic  route  the 
preferable.  When  sufficient  adhesions  are  present,  it  undoubtedly  is  ex- 
ceedingly safe,  but,  on  the  whole,  the  abdominal  route  is  the  better.  More 
cases  of  liver  abscess  can  be  reached  through  the  abdomen  than  through  the 
chest,  and,  while  a  satisfactory  examination  of  the  liver  for  secondary  and 
complicating  disease  is  possible,  the  dreaded  increased  danger  from  possible 
soiling  of  the  peritoneum  can  be  practically  completely  averted  by  suitable 
packing  with  gauze.  * 

SUBPHRENIC  ABSCESS. 

Subphrenic  abscess  is  commonly  a  sequel  of  perforative  gastric  ulcer,  of 
appendicitis,  and  of  hepatic  abscess;  its  treatment  may  be  merely  an  extension 
of  the  treatment  of  the  primary  disease.  The  treatment,  of  course,  consists 
in  evacuating  the  pus  and  in  securing  efficient  drainage.  The  pus  is  reached 
in  practically  the  same  manner  as  is  that  in  a  hepatic  abscess,  and  the  methods 
require  no  special  description.     Counter-openings  for  drainage  may  be  necessary. 


CHAPTER  XL. 
OPERATIONS  ON  THE  BILIARY  PASSAGES. 

Operations  on  the  gall-bladder  and  bile-ducts  are  most  commonly  required 
because  of  the  presence  of  gall-stones  or  of  infective  processes. 

Preparation  of  the  Patient. — The  preparation  for  the  operation  is  iden- 
tical with  that  for  almost  any  other  abdominal  operation,  but  when  chronic 
jaundice  is  present,  calcium  chloride  should  be  administered  by  the  mouth  in 
thirty-grain  (gr.  xxx)  doses  for  two  or  three  days  prior  to  the  operation,  and  in 
sixty-grain  (gr.  Ix)  doses  per  rectum  for  a  few  days  thereafter  (Mayo  Robson). 
This  rather  heroic  exhibition  of  calcium  chloride  is  the  great  preventive  of  the 
hemorrhage  which  is  so  often  fatal  after  operations  on  the  jaundiced.  All 
cases  of  obstruction  due  to  stone  in  the  common  duct,  in  which  purpuric  spots 
are  present  in  the  skin,  die  from  hemorrhage  if  operated  upon.  Some  of  these 
cases  when  treated  with  calcium  chloride  improve  sufficiently  for  operation  to 
become  justifiable. 


Fig.  538. 


Position  of  the  Patient. — Place  the  patient  on  his  back  and  support  the 
region  of  the  liver  on  a  firm  sand-bag  18  inches  long,  6  inches  wide,  and  31/2 
inches  deep.  This  opens  the  costal  angle  and  makes  the  intestines  gravitate 
from  the  field  of  operation;  it  also  pushes  "the  spine  forwards,  and  with  it  the 
liver  and  bile-ducts,  so  that  the  common  and  hepatic  ducts  are  brought  several 
inches  nearer  to  the  surface."  (Robson.)  This  position  (Robson's)  is  con- 
veniently obtained  without  the  use  of  a  sand-bag  on  the  table  shown  in  Fig.  538. 

454 


INCISIONS. 


455 


Methods  of  Exposure  of  the  Gall-bladder  and  Ducts. — ^\^ery  many 
incisions  have  been  advocated  and  used,  but  only  a  few  will  be  described. 

Method  A . — Mayo  Robson's  incision:  Make  a  vertical  incision  over  the  middle 
of  the  right  rectus  muscle.  Separate  the  fibres  of  the  muscle  with  the  fingers 
or  the  handle  of  a  scalpel.  Divide  the  posterior  sheath  of  the  rectus  and  the 
peritoneum  together.  This  incision  is  two  to  three  inches  in  length.  When 
it  is  necessary  to  explore  the  hepatic,  common,  or  deeper  portion  of  the  cystic 
ducts,  continue  the  orginal  incision  upwards  as  far  as  possible  in  the  space 
between  the  ensiform  cartilage  and  the  right  costal  margin  following  the  costal 
margin  (Fig.  539).  The  incision  is  similar  to  the  upper  part  of  Sevan's  inci- 
sion. It  freely  exposes  the  upper  surface  of  the  liver. 
Lift  the  lower  border  of  the  liver  in  bulk  (if  neces- 
sary, drawing  the  organ  downwards  from  under 
cover  of  the  ribs),  thus  bringing  the  whole  of  the 
gall-bladder  and  the  cystic  and  common  ducts  quite 
close  to  the  surface. '  As  the  gall-bladder  is  usually 
strong  enough,  let  the  assistant  take  hold  of  it  with 
his  fingers  or  forceps  and  by  gentle  traction  keep  the 
parts  well  exposed,  while  at  the  same  time  he  pro- 
tects and  retracts,  with  a  sponge  in  his  left  hand, 
the  left  side  of  the  wound  and  the  viscera,  which 
would  otherwise  obstruct  the  view.  "It  will  now  be 
observed  that  instead  of  the  gall-bladder  and  cystic 

duct  making  a  considerable  angle  with  the  common  duct,  an  almost  straight 
passage  is  found  from  the  fundus  of  the  gall-bladder  to  the  entrance  of  the 
bile-duct  into  the  duodenum,  and  if  adhesions  have  been  thoroughly  separated, 
the  surgeon  has  immediately  under  his  eye  the  whole  length  of  the  ducts  with 
the  head  of  the  pancreas  and  the  duodenum.  (Robson,  "Brit.  Med.  Jour.," 
January  24,  1903.) 

Method  B. — Sevan's  incision:  Bevan  criticizes  the  vertical  incision  in  the 
right  semilunar  line  as  being  insufficient,  and  when  long,  objectionable  because 
of  nerve  destruction;  a  T-shaped  incision  is  difficult  to  close  and  is  liable  to  lead 
to  hernia;  median  incision  does  not  give  free  access  to  the  gall-bladder.  He 
advocates  the  following  method  ("Annals  of  Surgery,"  xxx,  17):  Make  a 
vertical  incision  along  the  outer  border  of  the  right  rectus  muscle  or  between 
its  outer  fibres.  This  suffices  for  the  exploration  or  the  completion  of  a  simple 
cystostomy.  If  it  seems  necessary  to  expose  or  work  on  the  ducts,  enlarge 
the  incision  by  continuing  its  upper  end  obliquely  upwards  and  inwards,  its 
lower  end  obliquely  downwards  and  outwards.  This  gives  excellent  exposure 
and  does  little  injury  to  nerves,  but  it  necessitates  transverse  division  of  the 
abdominal  muscles. 

Method  C. — Kehfs  incision:  Kehr's  incision  is  very  similar  to  Bevan's 
and  possesses  similar  advantages  and  disadvantages.  From  the  ensiform 
process  make  a  cut  in  the  middle  line  downwards  for  about  i  1/2  inches;  then 


Fig.  539. 


4S6  OPERATIONS    ON   THE    BILIARY   PASSAGES. 

divide  the  right  rectus  obliquely  and  continue  the  cut  downwards  in  the  semi- 
lunar line. 

Method  D. — Kocher^s  oblique  incision:  Make  an  incision  four  inches 
in  length  parallel  to  and  about  two  inches  below  the  right  rib  margin.  This 
incision  divides  the  outer  fibres  of  the  rectus  muscle  and  portions  of  both  the 
internal  and  external  oblique.  Branches  of  the  intercostal  nerves  run  across 
the  incision  towards  the  rectus,  and  these  must  be  retracted  downwards  or 
upwards  and  preserved  uninjured.  Kocher's  incision  gives  very  free  access 
to  the  biliary  region,  but  necessitates  an  undue  amount  of  muscle  injury. 

Method  E. — Rutherford  Morison's  incision:  Make  a  transverse  incision 
from  the  ileo-costal  space  behind  to  the  outer  edge  of  the  rectus  in  front.  Be- 
sides giving  free  access  to  the  gall-bladder  and  ducts  this  permits  of  easy  pos- 
terior drainage. 

EXAMINATION  OR  EXPLORATION  OF  THE  GALL-BLADDER 

AND  BILE-DUCTS. 

When  the  abdomen  is  opened,  the  gall-bladder  is  usually  easily  recognized, 
and  it  is  easy  to  palpate  this  viscus,  to  follow  the  cystic  duct  downwards,  and, 
by  passing  the  finger  through  the  foramen  of  Winslow,  to  palpate  at  least  the 
supra-duodenal  portion  of  the  common  duct.  Often  the  gall-bladder  is 
hidden  in  a  mass  of  adherent  omentum  or  other  viscera,  or  it  may  be  much 
shrunken  as  well.  Under  these  circumstances,  beginning  at  the  liver  margin, 
separate  the  adhesions.  Use  the  liver  as  a  guide  to  the  site  of  the  gall-bladder. 
Many  of  the  adhesions  may  be  separated  by  the  fingers,  but  many  must  be 
cut  between  ligatures.  The  separation  of  adhesions  must  be  accomplished 
with  much  circumspection,  as  nature  occasionally  herself  performs  the  opera- 
tion of  cholecystenterostomy,  and  when  this  is  the  case,  the  surgeon  is  liable 
to  penetrate  the  junction  between  the  gall-bladder  and  the  gut.  When  this 
accident  occurs,  the  hole  in  the  gut  must  at  once  be  closed  by  a  double  line  of 
sutures.  When  the  gall-bladder  is  much  shrunken,  the  search  for  it  makes 
a  severe  call  on  the  patience  of  the  surgeon.  When  the  gall-bladder  is  dis- 
tended or  not  shrunken,  it  is  easy  to  pull  it  up  into  the  wound.  Before  break- 
ing down  adhesions  around  the  biliary  passages  be  careful  to  protect  thoroughly 
the  peritoneal  cavity  by  means  of  suitable  pads  or  sponges.  When  freeing  the 
gall-bladder  and  the  ducts  from  surrounding  adhesions,  one  is  liable  at  any 
moment  to  open  into  some  collection  of  infective  material,  and  dangers  from 
this  source  must  be  guarded  against.  As  was  hinted  when  describing  Robson's 
incision,  it  is  of  first-rate  importance  to  free  the  bile-ducts  from  surrounding 
adhesions;  if  this  is  not  done,  the  exploration  becomes  a  sham.  The  guide 
to  the  common  duct  is  the  gall-bladder  and  cystic  duct. 

OPERATIONS  ON  THE  GALL-BLADDER  AND  DUCTS. 

Ideal  Cholecystotomy. — This  operation  consists  in  opening  the  gall- 
bladder, removing  any  stones  which  it  may  contain,  and  closing  the  wound 


457 


Duodenum  3  Part- 

Aorta 

U:na  Cava 


L.Kidney 

Duodenum  4~/art 

Pancreatic  J)uct 

^^Sup.MesentericArt. 


Fig.  540. — Illustrating  the  relation  of  the  stomach,  pylorus,  duodenum,  pancreas,  bile- 
ducts,  etc.     Drawn  from  nature  by  Dr.  G.  G.  Davis,  at  the  request  of  the  author. 


CHOLECYSTOSTOMY,  459 

by  two  layers  of  sutures  exactly  as  one  would  close  a  wound  in  the  small  in- 
testine. Bernays  has  advocated  this  procedure  and  called  it  ideal.  Vautrin 
carried  out  a  similar  operation,  but  sutured  the  closed  viscus  to  the  upper 
part  of  the  abdominal  incision  (cholecystopexy) .  Union  of  ihe  gall-bladder 
to  the  upper  part  of  the  wound  has  the  advantage  that,  the  fundus  being  fixed 
in  an  elevated  position,  natural  drainage  of  the  viscus  is  aided.  Cholecys- 
totomy  is  rarely  if  ever  indicated,  since  to  be  justifiable  it  presupposes  a 
practically  normal  gall-bladder.* 

Cholecystostomy. — Cholecystostomy  is  an  operation  which  creates  a 
fistula  between  the  gall-bladder  and  the  parietes.  It  may  be  executed  in  either 
one  or  two  sittings;  usually  in  one. 

Cholecystostoniy  in  Two  Sittings. — First  sitting:  Expose  and  explore 
the  gall-bladder  and  ducts.  Bring  the  fundus  of  the  gall-bladder  into  the 
upper  part  of  the  abdominal  wound  and  suture  it  to  the  peritoneum  and  deepest 
layer  of  fascia  (transversalis  fascia),  but  not  to  the  skin.  It  is  said  that  the 
sutures  ought  not  to  penetrate  into  the  cavity  of  the  viscus,  but  should  merely 
include  a  portion  of  the  thickness  of  its  wall  (serous  and  muscular,  not  mucous, 
coats).  Close  the  rest  of  the  abdominal  wound  with  sutures.  It  is  well  to 
attach  a  long  silk  suture  to  the  exposed  portion  of  the  fundus  of  the  gall-bladder, 
to  act  as  a  guide  when  the  viscus  is  opened  at  a  later  date. 

Second  sitting:  In  a  few  days,  when  adhesions  have  formed  between  the 
gall-bladder  and  the  abdominal  wall,  make  an  opening  with  a  knife  into  the 
gall-bladder  and  so  establish  the  fistula. 

This  operation  is  eminently  safe  and  was  a  great  aid  in  establishing  the 
surgery  of  this  region,  but  to-day  the  operation  in  one  sitting  has  become 


Fig.  541. — Finney's  Block  Tin  Scoop. 

practically  as  safe  and  has  the  incomparable  advantage  that  it  permits  the 
finger  on  the  outside  of  the  gall-bladder  to  assist  in  the  extraction  of  calculi 
and  in  exploration.  When  the  finger  cannot  enter  the  abdominal  cavity  out- 
side the  gall-bladder,  the  extraction  of  all  the  calculi  present  becomes  a  matter 
of  extreme  uncertainty. 

Cholecystostomy  in  One  Sitting. — Expose  and  explore  the  gall-bladder 
and  ducts.  Separate  all  adhesions  which  impede  the  work.  Thoroughly 
protect  the  belly  cavity  with  gauze  pads.  If  the  gall-bladder  is  sufficiently 
large,  pull  it  up  into  the  abdominal  wound.  Seize  the  fundus  with  two  small 
volsella. 

If  the  organ  is  tensely  filled  with  fluid,  it  is  usually  advised  to  empty  it  by  means  of 
an  aspirator.  When  the  contents  are  thick,  and  they  usually  are  so,  a  small  aspirating 
needle  is  useless,  and  a  large  needle  puncture,  it  seems  to  the  writer,  possesses  no  advan- 
tages over  a  cut.     The  advantage  of  aspiration  is  avoidance  of  soiling  the  wound. 

*  In  a  personal  communication  Air.  Rutherford  Morison  informs  the  writer  that  he 
performs  cholecystotomy  frequently  and  he  has  had  no  cause  to  regret  it. 


460 


OPERATIONS    ON   THE   BILIARY   PASSAGES. 


Make  a  small  incision  into  the  viscus.  Mop  away  all  fluid  which  escapes. 
Enlarge  the  opening.  Remove  with  the  scoop  (Fig.  541)  any  calculi  which 
may  be  present  in  the  bladder  or  adjacent  portion  of  cystic  duct.  A  linger 
outside  the  gall-bladder  greatly  aids.  Often  stones  lying  in  the  cystic  and 
rarely  the  common  ducts  may  be  coaxed  by  the  finger  (outside  the  bladder) 
up  into  the  bladder  and  so  removed.  Too  much  time  must  not  be  expended 
in  trying  to  coax  such  stones  into  the  bladder,  as  other  and  surer  means  of 
extracting  them  are  available.  Once  more  explore  the  interior  of  the  gall- 
bladder with  the  finger.     Suture  the  opening  in  the  gall-bladder  to  the  parietal 

peritoneum  and  transversalis  fascia  in  the 
upper  part  of  the  abdominal  wound.  Gently 
cleanse  the  interior  of  the  bladder  with  gauze; 
temporarily  pack  the  cavity  with  gauze.  Re- 
move the  protective  pads  from  the  abdomen 
and  close  the  free  portion  of  the  abdominal 
wound.      Remove   the   temporary   pack  from 


Purae-String 
Suture 


Fig.  542. 


Fig.  543. 


the  gall-bladder  and  introduce  into  it  a  rubber  tube  (a  No.  25  F.  soft  catheter 
is  excellent).  Apply  abundant  dressings.  When  exploring  the  gall-bladder 
after  it  has  been  opened,  much  information  may  be  obtained  by  palpating 
with  a  finger  of  one  hand  inside  the  viscus  and  the  fingers  of  the  other  hand 
outside  it,  but  inside  the  belly.  Occasionally  one  finds  the  gall-bladder  ap- 
parently divided  into  two  cavities,  both  containing  calculi.  The  septa  between 
such  cavities  require  division  before  the  stones  can  be  removed.  In  suturing 
the  gall-bladder  to  the  parietes  J.  E.  Summers  does  not  sew  the  edge  of  the 
wound  in  the  viscus  to  the  abdominal  wound,  but  passes  his  sutures  through 
its  serous  and  muscular  tunics,  in  the  Lembert  fashion,  some  distance  away 
from  the  wound,  and  with  these  unites  the  bladder  to  the  parietes.  He  next  sur- 
rounds the  wound  in  the  bladder  by  a  purse-string  suture  involving  the  whole 
thickness  of  the  bladder-wall.  (Any  visible  or  oozing  branches  of  the  cystic 
artery  must  be  secured  by  running  this  or  the  preceding  suture  under  them; 
neglect  of  this  simple  percaution  has  permitted  a  fatal  hemorrhage.)  Then 
he  introduces  a  tube  into  the  bladder,  and  tightening  the  purse-string  suture, 
inverts  the  edges  of  the  wound  around  the  tube  (Figs.  541  and  543). 


CHOLECYSTOSTOMY. 


461 


The  Mayos  attain  the  same  end  as  follows:  Prepare  a  drainage-tube 
by  surrounding  it  with  a  few  layers  of  gauze  covered  by  rubber  tissue.  The 
end  of  the  tube  should  be  bevelled  or  trimmed  in  the  "fish-tail"  fashion. 
Introduce  this  "dressed  tube"  a  short  distance  into  the  gall-bladder.  With 
plain  catgut  suture  the  edges  of  the  gall-bladder  wound  snugly  to  the  tube. 
Push  the  tube  a  little  further  into  the  gall-bladder,  thus  inverting  that  portion 
of  the  gall-bladder  around  the  tube  and  the  original  line  of  suture.  With  a 
Lembert  suture  of  catgut  attach  the  surface  of  the  gall-bladder  all  around 
the  tube,  to  the  tube.  Leave  the  ends  of  this  last  suture  long,  and  with  a  needle 
attach  them  to  the  parietal  peritoneum. 

The  advantages  of  this  excellent  procedure  are:  (a)  The  purse-string 
suture  prevents  leakage  of  bile  around  the  drainage-tube,     (b)  WTien  the  tube 


!hvfR5ioN  5urufit 


^ 


Fig.  544. 


is  withdrawn,  the  inversion  of  the  bladder  wound  leaves  serous  surfaces  in 
contact,  there  is  no  prolapse  of  mucous  membrane,  and  hence  closure  of  the 
fistula  is  hastened. 

W.  D.  Jones  ("Annals  of  Surger}%"  xxvii,  53)  pulls  the  gall-bladder  well 
out  of  the  abdomen  and  sutures  the  parietal  peritoneum  to  the  viscus  at  a  dis- 
tance from  the  opening  into  it.  This  line  of  suture  corresponds  to  the  Lembert 
sutures  in  Fig.  544.  He  next  passes  a  catgut  suture  through  the  muscles  and 
fascia  of  the  parietes  into  the  gall-bladder,  just  external  to  the  peritoneal 
sutures,  then  with  same  suture  catches  the  edges  of  the  cystotomy  wound  and 
brings  the  suture  out  in  the  reverse  direction  to  that  in  which  it  was  introduced 
(Fig.  544). 

The  result  is  that  when  several  such  sutures  are  introduced  and  tightened, 
they  invert  the  cystotomy  wound  very  satisfactorily. 

When  the  surgeon  is  not  completely  satisfied  with  the  cleanliness  of  the 
abdomen  immediately  around  the  gall-bladder,  and  does  not  think  it  safe 


462  OPERATIONS    ON   THE    BILIARY   PASSAGES. 

to  close  the  abdomen  completely,  it  is  easy  to  pack  a  strip  of  gauze  immediately 
below  the  viscus  and  bring  its  end  out  through  a  hiatus  in  the  wound.  Such 
gauze  packing  the  author  leaves  in  situ  for  from  eight  to  ten  days,  and  has  never 
seen  any  reason  to  regret  having  left  it  this  long  period  of  time.  Adhesions  neces- 
sarily form  around  the  gauze  after  a  short  time,  and  if  it  is  removed  early,  the 
adhesions  are  liable  to  be  disturbed,  while  discharges  from  the  biliary  fistula  are 
very  apt  to  find  their  way  through  the  route  left  by  the  removal  of  the  gauze. 
After  the  lapse  of  eight  or  ten  days  there  is  no  danger  in  removing  the  gauze. 
To  prevent  the  gauze  sticking  to  the  stomach,  duodenum,  and  parietal  wound, 
thus  occasioning  crippling  adhesions,  it  may  be  surrounded  by  rubber  tissue 
(the  familiar  cigarette  drain). 

Cholecystectomy. — This  operation  is  called  for  under  several  conditions, 
such  as  the  presence  of  neoplasms,  lithiasis,  and  inflammation,  but  the  indi- 
cations necessitating  it  will  be  discussed  later. 

Step  I. — Exposure  and  exploration  of  the  gall-bladder  and  ducts. 

Step  2. — Aspiration  or  incision  of  the  gall-bladder  is  necessary  under  the 
following  circumstances  (Monod  and  Vanverts):  (i)  When  the  viscus  is  so 
distended  that  it  is  liable  to  rupture  during  the  necessary  manipulations.  (2) 
When  external  exploration  of  the  common  duct  leaves  doubt  as  to  its  permea- 
bility and  one  desires  to  catheterize  the  ducts  through  the  bladder.  One  must 
remember,  however,  that  the  valvular  construction  of  the  upper  part  of  the 
cystic  duct  does  not  lend  itself  to  easy  catheterization. 

In  the  absence  of  the  above  conditions  it  is  better  not  to  open  the  viscus 
and  thus  avoid  possible  contamination  of  the  wound. 

Step  3 — When,  as  exceptionally  happens,  the  gall-bladder  is  provided  with 
a  "meson,"  divide  this  between  ligatures  or  forceps.  As  a  rule,  the  viscus 
is  applied  directly  to  the  under  surface  of  the  liver  and  held  there  by  the  perit- 
oneum, and  one  operates  as  follows:  Incise  the  peritoneal  covering  of  the 
gall-bladder  and  by  blunt  dissection  separate  the  organ  from  the  liver.  Bleed- 
ing from  the  liver  may  be  controlled  by  suture,  by  the  use  of  the  Paquelin  cau- 
tery, or  by  sponge  pressure.  Isolate  and  ligate  the  cystic  branches  of  the 
hepatic  artery;  ligate  and  divide  the  cystic  duct.  If  it  is  desired  to  drain  the 
biliary  passages,  only  one  ligature  or  clamp  may  be  applied  between  the 
gall-bladder  and  the  point  of  section  of  the  duct;  if  complete  closure  of  the 
passage  is  sought,  then  the  duct  should  be  divided  between  two  ligatures. 
Riedel  under  the  latter  circumstances  closes  the  abdominal  wound  without 
drainage,  but  most  surgeons  agree  with  Kehr  that  it  is  safer  and  better  to  pack 
with  gauze  and  so  drain.  If  drainage  of  the  duct  is  required  or  desired,  leave 
the  stump  of  the  duct  open  and  suture  over  it  or  to  it  a  rubber  drainage-tube 
with  a  stitch  of  fine  plain  catgut.  This  stitch  will  be  absorbed  before  it  is 
time  to  remove  the  tube,  and  in  the  meantime  will  hold  it  in  place. 

Undoubtedly  cholecystectomy  is  best  accomplished  from  below  upwards — 
i.  e.,  beginning  by  dividing  the  duct.  There  are  two  principal  reasons  for 
this:     (a)  The  dissection  is  easier;  {b)  the  cystic  artery  (generally  two  branches) 


CHOLECYSTECTOMY. 


463 


is  ligated  at  the  same  time  as  the  duct  and  thus  hemorrhage  is  completely 
controlled  at  the  earliest  possible  moment. 

The  Operation. — Step  1. — Open  the  belly  by  Robson's  incision.  If  possible, 
pull  the  liver  to  a  large  extent  out  of  the  wound,  the  gall-bladder  being  used  as 
a  tractor  (Fig.  545). 

Step  2. — If  the  stone  is  present  in  the  cystic  duct,  apply  a  curved  forceps 
to  the  duct  below  the  stone. 


.  Fig.  545. — {Mayo.)     From  sketches  by  the  author. 

Step  3. — Divide  the  duct,  and  incidentally  the  cystic  artery,  between  the 
forceps  and  the  stone.  The  stone  acts  as  a  plug  to  the  part  of  the  duct  left  at- 
tached to  the  gall-bladder.  If  no  such  plug  is  present,  apply  a  second  forceps 
and  cut  between  the  two  forceps  (Fig.  545). 

Step  4. — Dissect  free  from  its  attachments  a  short  segment  of  the  duct 
still  attached  to  the  gall-bladder.  This  is  to  give  space  for  the  next  step.  Do 
not  yet  attempt  to  remove  the  bladder — it  is  of  too  great  value  as  a  tractor. 

Step  5. — Apply  a  ligature,  preferably  of  stout  catgut,  around  the  stump 
of  the  cystic  duct  {i.  e.,  the  stump  continuous  with  the  common  duct).     To 


464 


OPERATIONS    ON    THE    BILIARY    PASSAGES. 


prevent  slipping,  this  ligature  must  be  applied  with  a  needle,  penetrating  the 
tissues.  Retain  control  of  the  stump  by  catching  it  with  a  hemostat.  Remove 
the  original  forceps.  If  bleeding  occurs^it  is  sometimes  free  enough  to 
alarm  the  inexperienced — stanch  it  by  the  insertion  of  a  few  more  stitches, 
with  the  same  needle  and  ligature  which  surrounds  the  duct.  Hemostasis 
■must  be  absolute.     Leave  the  ends  of  the  ligature  long. 

Step  6. — Grasp  the  lower  end  of  the  duct,  still  attached  to  the  gall-bladder, 
and  pull  it  towards  the  surface  (Fig.  546) ;  as  this  is  done,  by  blunt  and  sharp 
dissection  free  the  gall-bladder  from  the  liver,  working  from  below  .upwards. 


Fig.  546. — {Mayo.)     From  sketches  by  the  author. 


As   a  rule,  bleeding  is  practically  nil;  if  it  is  free,  it  may  be  stopped  by  the 
sutures  applied  in  the  next  step. 

Step  7. — The  gall-bladder  having  been  removed,  a  raw  surface  is  left  on 
the  liver;  this  surface  is  bordered  by  flaps  of  peritoneum  which  originally 
bound  the  gall-bladder  to  the  liver.  Suture  these  flaps  together  by  a  few 
fine  catgut  sutures.  If  necessary,  these  sutures  may  bite  into  the  liver 
and  assist  in  hemostasis.     Leave  the  ends  of  these  interrupted  sutures  long 

(Fig.  546). 

Step  8. — Make  a  roll  of  gauze  (mildly  iodoformized)  about  i  1/4  inches 
wide  and  1/3  inch  thick  and  4  or  5  inches  long.  Over  one  side  of  this  place  a 
layer  of  rubber  tissue.  Around  one  end  of  this  roll  tie  a  ligature  of  fine  plain 
catgut.  Tie  this  fine  catgut  to  the  ligature  surrounding  the  stump  of  the  duct, 
so  that  the  roll  of  gauze  is  held  snugly  against  the  stump  and  covers  it.  Lay 
the  roll  of  gauze  (with  the  rubber  tissue  next  the  abdomen,  the  gauze  next  the 


CHOLECYSTENTEROSTOMY.  465 

liver)  along  the  site  from  which  the  gall-bladder  was  excised.  Tie  the  sutures 
inserted  during  Step  7  over  the  roll  of  gauze.  Bring  the  end  of  the  gauze  out 
of  the  abdominal  wound.     Close  the  abdominal  wound. 

When  the  duct  end  of  the  gall-bladder  is  much  more  adherent  and  anatomy 
is  rendered  very  obscure,  the  above  operation  or  any  ordinary  cystectomy  is  out 
of  place.  The  Mayos'  method  of  removing  the  most  of  the  gall-bladder  and 
all  the  mucosa  of  the  remnant  of  that  viscus  and  of  the  cystic  duct  is  much 
easier  than  cystectomy,  as  efficacious,  and  infinitely  safer. 

The  'Mayos'  Operation. — In  cases  where  it  is  desirable  to  obliterate  the 
gall-bladder  ultimately,  but  in  the  mean  time  to  use  it  as  a  means  of  draining 
the  biliary  passages,  it  is  wise  to  operate  as  follows:  Expose,  explore,  and 
open  the  viscus  as  in  cholecystostomy.  Amputate  the  fundus  and  most 
of  the  gall-bladder.  Excise  the  mucosa  from  the  remainder  of  the  gall-blad- 
der and  adjacent  part  of  the  cystic  duct,  beginning  with  the  duct  mucosa. 
Pass  a  "dressed  drainage-tube" — i.  e.,  one  covered  by  gauze  and  rubber 
tissue — into  the  duct  and  suture  the  remnant  of  the  gall-bladder,  with  cat- 
gut, tightly  to  the  tube.  When  the  drain  is  removed,  the  gall-bladder  becomes 
a  fibrous  cord. 

Cholecystenterostomy. — When  the  common  duct  is  irreparably  oc- 
cluded, e.  g.,  by  malignant  disease,  or  when  it  is  desirable  to  drain  the  ducts 
in  chronic  pancreatitis,  the  formation  of  a  fistula  between  the  gall-bladder 
and  the  gut  permits  the  escape  of  bile.     This  operation  is  cholecystenterostomy. 

(A)  Antero-colic  method.  WTien  possible,  it  is  best  to  unite  the  gall- 
bladder to  the  duodenum  but  under  stress  of  circumstances  that  portion  of 
the  intestine  (even  the  colon)  which  is  most  readily  brought  up  against  the 
gall-bladder  is  the  best  portion  to  use.  The  operation  itself  is  practically 
identical  with  that  of  entero-enterostomy  (intestinal  anastomosis)  and  re- 
quires no  special  description.  It  may  be  accomplished  by  the  method  of 
suture,  by  McGraw's  elastic  suture,  or  by  the  Murphy  button.  Probably 
the  oldest  patient  ever  submitted  to  this  operation  was  a  woman  eighty  years 
of  age,  in  whom  the  author  successfully  used  the  Murphy  button.  Before 
the  operation  of  choledochotomy  was  as  safe  as  it  is  to-day,  cholecystenterostomy 
was  much  more  frequently  resorted  to  than  at  present;  it  averted  the  evils 
from  obstruction  of  the  common  duct  by  stones,  but  it  did  not  rid  the  patient 
of  the  obstruction  itself  or  of  the  late  effects  of  the  irritation  from  the  obstruct- 
ing calculus. 

WTien  the  gall-bladder  is  anastomosed  to  a  segment  of  small  intestine, 
it  has  been  suggested  that  an  anastomosis  between  the  afferent  and  efferent 
segments  of  the  gut  would  prevent  all  possibility  of  intestinal  contents  gaining 
access  to  the  gall-bladder.  This  precaution  seems,  to  the  author,  superfluous, 
as  it  would  not  prevent  the  passage  of  the  ever-present  infection  from  the 
intestine  into  the  gall-bladder,  even  if  it  did  keep  the  gross  contents  of  the 
intestine  from  entrance  into  that  viscus.  The  increased  danger  of  the 
extra  operation  seems  out  of  proportion  to  the  benefit  to  be  obtained. 


466  OPERATIONS    ON    THE    BILIARY   PASSAGES. 

(B)  Retro-colic  Method.  (Brentano,  "Zentralblatt  fiir  Chir.,"  1907, 
No.  24.     Lotheisen,  idem.,  No.  31.) 

Step    I. — Open    the    abdomen.     Explore    the    gall-bladder    and    ducts. 

Step  2. — Pull  the  transverse  colon  and  great  omentum  out  of  the  wound 
and  turn  them  upwards  exactly  as  in  posterior  gastro-enterostomy.  Find 
the  duodeno-jejunal  junction;  select  a  portion  of  jejunum  about  12  inches 
below  the  junction;  select  a  bloodless  portion  of  the  transverse  mesocolon 
close  to  the  gall-bladder  and  tear  a  hole  in  it  as  in  gastro-enterostomy.  Pull 
the  selected  loop  of  jejunum,  from  below  upwards  through  the  rent  in  the 
mesocolon.  Apply  an  intestinal  clamp  {e.  g.,  Doyen's)  to  the  jejunum.  Re- 
turn the  colon  and  omentum  into  the  belly. 

Step  3. — If  the  gall-bladder  is  distended  empty  it  by  means  of  a  trocar 
and  cannula  introduced  at  its  dome.     Close  the  puncture. 

Step  4. — Choose  a  suitable  portion  of  the  under-surface  of  the  gall-bladder 
and  to  it  apply  an  intestinal  clamp.  Lay  the  clamped  loop  of  jejunum  against 
the  clamped  loop  of  gall-bladder  and  make  an  anastomosis.  If  the  Murphy 
button  is  used  it  is  unnecessary  to  clamp  the  gall-bladder. 

Step  5. — Once  more  pull  the  colon  and  omentum  upwards  so  as  to  expose 
the  transverse  mesocolon.  Pull  the  jejunum  downwards  until  the  line  of  the 
anastomosis  becomes  visible  below  the  rent  in  the  mesocolon.  With  a  few 
stitches  tack  the  edges  of  the  rent  in  the  mesocolon  to  the  line  of  anastomosis. 
Return  the  colon  and  omentum  to  the  abdomen. 

No  argument  is  necessary  to  show  the  superiority  of  the  retrocolic  method 
of  cholecystenterostomy  over  the  older  method. 

Cysticotomy — Incision  into  the  Cystic  Duct. — When  calculi  are  pres- 
ent in  the  cystic  duct,  it  is  often  possible  to  extract  them  through  the  gall- 
bladder. If  this  is  not  easy  to  accomplish,  one  should  not  waste  much  time 
in  such  endeavors,  but  should  carefully  locate  the  stones,  incise  the  duct 
longitudinally  over  them,  and  extract  them.  The  wound  in  the  duct  may 
be  closed  by  sutures.  The  sutures,  if  of  silk  or  hemp,  must  not  penetrate 
the  mucosa  lest  they  form  the  nuclei  of  more  calculi.  Catgut  sutures  are 
excellent  and  have  not  this  disadvantage.  Many  surgeons  insert  but  do  not 
tie  the  sutures  before  the  stones  are  removed.  The  suturing  is  not  so  difhcult 
as  might  be  imagined,  because  from  disease  the  ducts  are  dilated  and  their 
walls  thickened.  It  is  important  to  remember  that  not  much  time  should 
be  devoted  to  attempts  at  suturing  (the  writer  has  seen  death  result  from 
such  waste  of  time),  since  really  quite  as  good  results  are  obtained  by  drainage 
of  the  unsutured  passages.  The  Mayos'  suggestion  of  suturing  (with  plain 
catgut)  a  rubber  drain  to  the  open  duct  and  surrounding  this  with  a  gauze 
pack  is  a  most  excellent  practice,  and  is  eminently  safe.  On  the  whole,  the 
inexperienced  operator  is  advised  to  avoid  attempts  at  suturing  the  ducts; 
the  Robsons  of  our  profession  require  no  advice,  and  are  marvelously  deft 
with  the  needle. 

Instead  of  making  a  separate  incision  into  the  duct  one  may  follow  Del- 


CHOLEDOCHOTOMY.  467 

ageniere's  plan  of  continuing  the  incision,  already  existing  in  the  gall-bladder, 
downwards  so  as  to  split  the  cystic  duct  until  the  stone  is  exposed.  If  necessary 
the  whole  length  of  the  duct  may  be  split  in  the  above  fashion.  Terrier, 
Hartmann  and  others,  when  dealing  with  stones  in  the  common  duct,  spilt 
the  gall-bladder,  cystic  duct  and  as  much  of  the  common  duct  as  may  be  nec- 
essary to  expose  and  remove  the  stone,  after  which  they  remove  the  gall-blad- 
der, pass  a  rubber  drain  far  up  the  hepatic  duct  (Kehr's  "hepaticus  drainage") 
and  pack  a  little  gauze  around  the  tube.  The  tube  and  pack  are  brought 
out  of  the  abdominal  wound,  the  excess  of  which  is  closed.  It  is  a  wise  pre- 
caution to  anchor  the  drain  and  pack  to  the  ducts  by  fine  catgut  sutures. 

The  advantages  of  splitting  the  gall-bladder  and  ducts  are  that  they  form 
an  infallible  guide  to  the  stone  and  the  vnde  opening  permits  of  very  free 
exploration.  The  disadvantages  are  the  difficulty  of  doing  the  work  when 
many  adhesions  are  present,  and  the  extent  of  the  wound  inflicted.  On 
several   occasions   the   author  has  found   the   procedure   very   useful. 

Choledochotomy — Incision  into  the  Common  Bile-duct. — The  common 
bile-duct  may  be  considered  as  consisting  of  two  parts:  one,  supraduodenal, 
stretching  from  the  junction  of  the  cystic  and  hepatic  ducts  to  the  union  of 
the  first  and  second  segments  of  the  duodenum;  the  other  part,  retroduodenal, 
stretching  the  remainder  of  the  distance  to  the  ampulla  of  Vater. 

The  supraduodenal  portion  of  the  choledochus  is  about  3/4  to  i  inch 
in  length  and  occupies  the  right  margin  of  the  gastro-hepatic  omentum.  To 
the  left  and  behind  the  duct  lies  the  portal  vein — further  to  the  left  is  the  hepatic 
artery.  When  the  duct  is  dilated  by  disease,  the  portal  vein  may  lie  in  front 
of  it.  The  dangers  from  this  source  have  been  grossly  exaggerated.  In 
operations  the  portal  vein  and  hepatic  artery  are  rarely  seen.  The  line  for 
safe  incision  is  along  the  anterior  and  right  side  of  the  duct.  The  foramen 
of  Winslow  is  the  guide  to  the  duct.  A  finger  passed  into  the  foramen  and 
hooked  forwards  inevitably  brings  the  duct  forwards  also.  Unfortunately, 
the  foramen  of  Winslow  is  sometimes  hidden  or  obliterated  by  adhesions. 
Several  lymphatic  glands  exist  in  the  gastro-hepatic  omentum,  and  when 
enlarged  may  lead  to  error.  The  retroduodenal  portion  of  the  choledochus 
runs  for  a  distance  of  about  2  inches  along  the  posterior-internal  border  of 
the  second  part  of  the  duodenum.  The  duct  for  about  i  1/4  inches  before 
it  reaches  the  ampulla  of  Vater  lies  on  or  in  the  pancreas.  It  is  evident  that 
the  retroduodenal  portion  of  the  duct  covered  by  intestine  and  pancreas  is 
out  of  reach  of  palpation  by  ordinary  means.  To  add  to  the  difficulties;  sev- 
eral lymphatic  glands,  prone  to  enlargement,  exist  along  this  tract  and  render 
a  positive  diagnosis  as  to  the  presence  or  absence  of  stone  impossible  without 
further  exposure.  Vautrin  ("Revue  de  Chirurgie,"  June,  1896)  has  made 
an  extremely  exhaustive  and  important  study  on  the  anatomy  and  surgery 
of  the  retroduodenal  choledochus,  and  the  following  is  based  on  his  writings: 

Exposure  of  the  Retroduodenal  Choledochus  {Vautrin's  Operation). — Make 
traction  on  the  second  or  descending  portion  of  the  duodenu  m.     This  makes 


468  OPERATIONS    ON    THE    BILIARY    PASSAGES. 

prominent  the  junction  of  the  intestine  and  the  gastro-hepatic  omentum. 
Beginning  at  this  prominent  point,  incise  the  peritoneum  parallel  to  the  con- 
vexity of  the  duodenal  angle,  and  prolong  the  incision  along  the  external 
border  of  the  second  segment  of  the  duodenum,  so  as  to  free  it  from  its  ex- 
ternal serous  attachments.  This  soon  exposes  that  portion  of  the  duct  which 
lies  in  a  groove  on  the  anterior  surface  of  the  pancreas.  Lower  down  the 
duct  is  embedded  in  the  pancreas  and  the  exposure  is  more  difficult,  as  vari- 
ous lobules  of  the  gland  lying  between  the  duct  and  the  intestine  are  closely 
adherent  to  the  muscular  coats  of  the  latter.  Blunt  dissection  alone  no  longer 
avails;  the  scissors  must  be  employed  and  portions  of  pancreatic  tissue  must 
be  sacrificed  rather  than  intestinal  wall.  One  and  one-fourth  inches  of  the 
duct  may  be  exposed  as  above.  A  further  exposure  may  be  made,  but  to 
do  this  the  thermocautery  ought  to  be  employed  because  of  the  numerous 
veins  present.  By  the  above  measures  the  duct  can  be  exposed  to  a  point 
about  3/8  inch  from  the  ampulla  of  Vater. 

Without  previous  knowledge  of  Vautrin's  researches  Cooper,  of  San  Fran- 
cisco, came  to  almost  identical  conclusions  from  his  studies  on  the  cadaver 
("Annals  of  Surgery,"  vol.  ii,  1903).  Abbe  also  describes  a  similar  method. 
These  operations  seem  better  suited  to  the  dissecting-  than  the  operating- 
room. 

WTien  the  finger,  passed  through  the  foramen  of  Winslow,  palpates  stones  in 
the  upper  portion  of  the  common  duct  and  the  stones  cannot  easily  be  coaxed 
back  into  the  gall-bladder  for  removal — ^how  should  they  be  treated?  In  the 
earlier  days  of  the  surgery  of  this  region  several  plans  were  devised,  and  under 
exceptional  circumstances  might,  even  to-day,  be  practised. 

1.  The  stones  can  be  crushed  in  situ  between  the  blades  of  forceps  pro- 
tected by  rubber  tubing.  This  treatment  is,  of  course,  liable  to  injure  the 
duct-walls,  and  in  spite  of  careful  cleansing  of  the  duct  through  the  gall- 
bladder is  certain  to  leave  detritus  which  may  or  may  not  be  passed  per  vias 
naturales. 

2.  Needles  may  be  passed  through  the  duct- walls  and  into  the  stones 
so  as  to  facilitate  their  fragmentation.  The  same  objections  apply  here 
as  to  the  cholelithotrity  by  forceps. 

3.  The  stones  may  be  left  in  situ,  and,  the  cystic  duct  and  gall-bladder 
being  free,  the  operation  of  cholecystenterostomy  may  be  performed.  This 
overcomes  the  dangers  of  biliary  obstruction,  but  does  not  obviate  the  dangers 
inherent  to  the  presence  of  retained  duct  stones,  viz.,  irritation  leading  to 
inflammation  and  malignant  disease. 

To-day  the  operation  of  choice  is  choledochotomy,  or  incision  into  the 
duct  directly  over  the  stone.  The  portion  of  the  duct  affected,  exposed  as 
described,  is  grasped  or  steadied  by  the  fingers,  and  an  incision  is  made  along 
it,  over  the  stone,  of  size  sufficient  to  permit  of  the  easy  extraction  of  the  cal- 
culus. If  it  is  desired  to  close  the  duct  wound  with  sutures,  such  should  be 
introduced  but  not  tightened   before   the   stone  is   removed.     The   stitches, 


CHOLEDOCHOTOMY.  469 

if  of  silk,  include  the  serous  and  muscular  coats  of  the  duct,  but  not  the  mu- 
cous. Comparatively  few  surgeons  use  sutures,  preferring  to  rely  on  drainage 
until  such  time  as  closure  of  the  duct  takes  place  naturally.  The  late  Dr. 
Davis,  of  Alabama,  was  responsible  for  this  advance.  Having  opened  the 
duct  and  removed  the  calculi  present  at  the  site  of  incision,  pass  a  probe  down- 
wards to  the  duodenum  to  insure  the  patency  of  the  duct  below,  and  upwards 
into  the  hepatic  duct  to  explore  for  any  calculi  there  present.  This  is  the 
advice  usually  given,  but  it  is,  in  fact,  impossible  by  means  of  the  probe  posi- 
tively to  exclude  the  presence  of  stones;  only  by  palpation  with  the  finger 
inside  the  duct  can  positive  knowledge  be  attained.  Kehr  strongly  recom- 
mends that  a  rubber  drain  be  passed  up  into  the  hepatic  duct  so  as  to  provide 
exact  drainage.  Most  surgeons  pass  a  rubber  drain  down  to  the  duct,  fix 
it  there  with  a  stitch  of  plain  catgut,  surround  it  with  a  pack  of  gauze  covered 
by  rubber  tissue,  and  close  the  external  wound  except  where  the  drain  and 
pack  emerge. 

Even  if  the  wound  in  the  duct  be  sutured,  drainage  is  essential.  When 
the  gall-bladder  has  been  opened,  it  may  be  treated  in  various  ways:  (a) 
It  may  be  excised^cholecystectomy.  (b)  The  opening  in  it  may  be  sutured 
to  the  parietes — cholecystostomy.  (c)  It  may  be  drained  in  the  same  fashion 
as  the  common  duct  is  drained. 

The  Mayo  brothers  have  systematized  the  operation  of  choledochotomy 
in  the  following  manner: 

Step  I. — Open  the  belly  by  the  Robson  incision.  Separate  adhesions 
and  explore  the  gall-bladder  and  ducts.  If  the  gall-bladder  is  distended  re- 
move part  or  all  of  its  fluid  contents  by  the  trocar  and  cannula  or  by  incision. 
The  gall-bladder  in  case  of  common-duct  stone  is  commonly  much  shrunken. 

Step  2. — Pull  part  of  the  liver  out  of  the  wound  and  towards  the  right. 
This  exposes  the  ducts  and  brings  them  within  reach.  Protect  the  belly 
cavity  with  gauze  packs.  With  the  fingers  palpate  the  stone  in  the  duct, 
and  steady  it  so  that  it  can  act  to  the  duct  the  part  of  a  ball  thrust  into  a  stock- 
ing that  is  being  darned.  (Elliot.)  Introduce,  longitudinally,  two  fine  plain 
gut  sutures  into  the  duct  (Fig.  547).  These  penetrate  the  whole  thickness 
of  the  duct-wall,  if  such  is  necessary  to  get  a  firm  hold.  Using  the  sutures 
as  tractors,  make  an  incision  into  the  duct  over  the  stone.  Extract  the  stone. 
Explore  the  duct  with  the  finger  in  it.  The  finger  passed  up  the  duct  and 
pulled  out  again  (slightly  crooked  when  being  pulled  out)  acts  as  the  piston 
of  a  pump  and  sucks  down  any  small  stones  which  may  be  in  the  upper  part 
of  the  common  or  in  the  hepatic  ducts.  In  the  large  majority  of  cases  the 
finger  can  and  must  be  passed  up  to  the  division  of  the  hepatic  duct  and  down 
to  the  papilla;  this  can  be  much  simplified  by  exerting  counterpressure  on 
the  duodenum  and  pancreas.  Ducts  not  large  enough  to  admit  the  finger 
are  usually  thin-walled,  not  much  adherent,  and  hence  palpable  from  the 
outside.  It  is  only  in  difficult  cases,  i.  e.,  where  many  adhesions  are  present 
and  the  duct-walls  are  thickened,  that  finger  exploration  inside  the  duct  be- 


470 


OPERATIONS    ON    THE    BILIARY    PASSAGES. 


comes  absolutely  necessary.  In  all  cases  when  it  is  possible,  this  method 
of  exploration  should  be  used.  Diverticula  hide  stones  from  the  probe  or 
scoop,  as  the  nature  of  the  calculi  lets  them  give  no  feeling  of  "grit"  when 
touched  by  metal;  only  the  finger  can  recognize  them. 

Step   3. — -Treatment  of  the  wound  in  the  duct. 

(A)  If  it  is  possible  to  do  a  cholecystostomy,  and  the  cystic  duct  is  sufficiently 
patent  to  permit  of  biliary  drainage,  the  wound  in  the  duct  may  be  treated 
as  follows:  Cross  the  one  end  of  suture  x  with  that  of  suture  Y  (Fig.  548), 
and  the  end  of  suture  x'  with  that  of  suture  y^  but  do  not  tie  them.     Place 


Fig.  547.- — {Mayo.)     From  sketches  by  the  author. 


the  strip  of  gauze  g  (Fig.  549)  longitudinally  over  the  wound  in  the  duct  and 
over  the  crossed  sutures.  Tie  the  sutures  around  the  gauze  strip,  the  free 
side  of  which  is  covered  by  a  layer  of  rubber  tissue.  This  closes  the  wound 
and  fixes  the  gauze  over  it,  so  that  should  bile  escape  it  cannot  wash  away 
the  gauze,  and  an  efficient  drain  is  provided.  Bring  the  end  of  the  gauze 
out  through  the  abdominal  wound.  Establish  a  cholecystostomy.  Close  the 
excess  of  abdominal  wound. 

(B)  If  owing  to  the  small  size  or  the  diseased  condition  of  the  gall-bladder 
a  cholecystostomy  is  impossible  or  improper,  proceed  as  follows:  Prepare 
a  1/4-inch  tubular  drain  wrapped  with  gauze  to  within  a  distance  of   1/3 


CHOLEDOCHOTOMY. 


471 


inch  of  its  end.  Introduce  the  bared  end  of  the  tube  into  the  common  duct; 
the  covering  of  gauze  prevents  its  going  in  too  far.  Thread  one  end  of  the 
suture  x-x^  on  a  needle,  pass  it  through  the  tube  and  tie  it  to  the  other  end 
of  the  same  suture.     Do  the  same  with  suture  y-y^     Bring  the  end  of  the 


Fig.  548. 


Fig.  549. 


Fig.  550. 


Fig.  551. 


dfain  out  of  the  wound  and  close  the  excess  of  abdominal  wound  (Fig,  550). 
The  end  of  the  tube  introduced  into  the  duct  should  be  beveled  or  cut  in 
the  "fishtail"  fashion.  A  small  gauze  pack  around  the  above  and  tied  to 
the  suture  y-y^  or  x-x^  is  an  added  safety. 


472 


OPERATIONS    ON   THE   BILIARY   PASSAGES. 


(C)  Hepaticus  drainage.  Through  the  wound  in  the  common  duct  in- 
troduce a  drainage  tube  upwards  to  beyond  the  opening  of  the  cystic  duct. 
The  best  tube  to  use  is  a  soft-rubber  catheter  (No.  25  to  30  F.),  with  its  end 
cut  ofif  and  a  lateral  opening  made  about  3/4  inch  from  its  extremity.  Fix 
the  tube  to  the  wound  by  a  catgut  stitch  (Fig.  551).  Close  the  excess  of  the 
wound  in  the  duct  and  the  hepato-colic  omentum  by  a  continuous  catgut 
stitch.  Drain  the  gall-bladder  with  a  dressed  rubber  drain.  Between  the 
neck  of  the  gall-bladder  and  the  wound  in  the  common  duct,  place  a  strip 
of  iodoform  gauze.  With  fine  catgut  stitch  the  end  of  a  large  split  rubber 
tube  to  the  common  duct  immediately  below  the  exit  of  the  drain.  (The 
same  suture  used  for  closing  the  duct  wound  is  suitable  for  fixing  the  large 


Fig.  552. 


split  tube.)  Make  the  split  tube  embrace  or  almost  embrace  the  common 
duct  drain,  the  gall-bladder  drain  the  strip  of  gauze  and  any  other  drain  which 
may  be  required  (Fig.  552).  Tie  a  thread  of  catgut  round  the  split  tube  so 
as  to  hold  all  these  drains  together,  and  let  them  all  protrude,  as  one,  through 
the   abdominal   wound. 

Another  method  of  reaching  the  calculus,  viz.,  by  sphtting  the  gall-bladder 
and  both  the  cystic  and  common  ducts,  is  described  under  cysticotomy. 

When  the  obstructing  calculus  exists  very  low  down  in  the  common  duct, 
one  may  reach  it  by  the  transduodenal  route.  McBurney  ("Annals  of  Sur- 
gery," Oct.,  1893)  was  the  first  to  perform  this  operation  of  duodeno-choledo- 
chotomy.  Kocher  is  a  supporter  of  the  method.  Mr.  Mayo  Robson  thus 
describes  the  procedure: 

"The  termination  of  the  common  duct,  including  the  duodenum,  should 


HEPATO-ENTEROSTOMY.  473 

be  grasped  between  the  finger  and  the  thumb  of  the  left  hand  and  the  ante- 
rior wall  of  the  gut  cut  through,  thus  exposing  the  interior  of  the  posterior  wall 
of  the  intestine  with  the  termination  of  the  common  duct  running  in  it.  Either 
the  duct  can  be  laid  open  from  the  papilla,  or  the  stone  may  be  cut  down 
on,  through  the  posterior  wall  of  the  duodenum.  Bile  flows  freely  as  soon 
as  the  obstruction  is  removed,  and  it  must  be  mopped  away  as  it  flows,  since 
it  always  contains  pyogenic  microbes  and  is  therefore  infectve.  As  a  rule, 
there  will  be  no  trouble  with  bleeding  and  no  sutures  need  be  placed  in  the 
posterior  wall  of  the  duodenum.  The  incision  through  which  the  duodenum 
has  been  opened  should  be  sutured  by  a  continuous  catgut  suture  for  the 
mucous  membrane  and  a  continuous  silk  suture  for  the  peritoneum.  No 
drainage  is  required.  For  calculi  situated  in  the  lower  third  of  the  common 
duct,  especially  if  impacted  in  the  diverticulum  of  Vater,  the  operation  is 
decidedly  preferable  to  the  ordinary  choledochotomy,  as  not  only  is  it  easier, 
but  an  incision  of  the  narrow  orifice  of  the  bile-duct  in  the  duodenum  leaves 
a  patent  opening,  which  will  allow  any  other  concretions  that  may  have  es- 
caped observation  to  pass  without  difiiculty."  ("Dis.  Gall-bladder  and  Bile- 
ducts,"  1901,  p.  269.) 

Sencert  ("Revue  de  Gynecologie  et  de  Chir.  Abdom.,"  x,  47)  gives  the 
following  anatomical  rules  for  finding  the  ampvdla  of  Vater  by  the  duodenal 
route,  (a)  Observe  whether  the  ascending  colon  is  fixed  or  is  provided 
with  a  mesocolon,  (b)  If  the  ascending  colon  is  fixed  (80  per  cent.),  incise 
the  duodenum  transversely  immediately  above  that  portion  or  angle  of  the 
colon  which  lies  on  its  anterior  surface,  (c)  If  the  ascending  colon  has  a 
meson  (20  per  cent.),  find  the  root  of  the  transverse  mesocolon  and  incise  the 
duodenum  immediately  above  this.  This  leads  directly  to  the  ampulla  of 
Vater. 

J.  C.  Hancock  ("Annals  of  Surg.,"  Jan.,  1906)  has  collected  62  cases 
in  which  the  common  duct  has  been  reached  through  the  duodenum.  The 
death  rate  was  12.6  per  cent.  In  57  of  the  cases  operation  was  for  the  re- 
moval of  gall-stones,  in  2  for  the  relief  of  neoplastic  obstruction  of  the  papilla 
and  in  2  for  the  removal  of  pancreatic  calculi. 

Kehr  and  Mayo  have  supplemented  the  operation  by  opening  the  com- 
mon duct  high  up  and  pulling  strips  of  gauze  through  the  duct  from  one  open- 
ing to  the  other,  thus  insuring  the  removal  of  all  fragments  of  stone. 

Hepato-cholangio-enterostomy. — This  operation  consists  in  effecting 
an  anastomosis  between  the  gut  and  the  smaller  hepatic  ducts.  It  is  indicated 
in  those  cases  in  which  there  is  present  permanent  obstruction  of  the  common 
and  main  hepatic  ducts  or  of  the  common  and  cystic  ducts.  Under  the  above 
circumstances  a  cholecystenterostomy  would  be  useless,  and  a  cholangiostomy 
(i.  e.,  a  union  of  the  opened  small  bile-ducts  to  the  skin)  as  practised  by  Kocher 
and  Langenbuch  is  objectionable,  as  it  establishes  a  permanent  biliary  fistula. 
Hepato-cholangio-enterostomy  was  suggested  by  Baudouin,  and  Langenbuch, 
but  first  practised  by  Hans  Kehr.     ("  Centralblatt  f.  Chir.,"   1904,  No.  7.) 


474  OPERATIONS    ON   THE    BILIARY   PASSAGES. 

The  Operation. — Step  i. — Exposure  of  gall-bladder  region,  preferably  by 
Mayo  Robson's  incision.     If  necessary,  excise  the  gall-bladder. 

Step  2. — From  a  convenient  part  of  the  lower  margin  of  the  liver  excise  a 
strip  of  liver  tissue  about  two  and  one-half  inches  long  by  about  one  inch  wide. 
With  the  thermocautery  stop  the  hemorrhage  and  at  the  same  time  burn  a  hole 
in  the  liver  of  such  a  depth  that  several  moderate-sized  bile-ducts  are  opened' 

Step  3. — Choose  a  segment  of  gut,  preferably  doudenum,  which  can  be 
brought  up  to  the  hepatic  wound  without  tension.  In  this  gu  make  an  opening 
21/2  inches  long,  and  suture  it  to  the  margins  of  the  liver  wound.  In  Kehr's 
case  only  a  few  sutures  cut  loose  while  being  tied,  and  he  was  able  to  close  the 
belly  without  packing  the  wound.  In  most  cases  one  imagines  that  packing 
with  iodoform  gauze,  or  at  least  the  use  of  one  or  more  cigarette  drains,  would 
be  of  much  value.  In  the  case  operated  upon  recovery  ensued  and  the  liver 
tissue  seemed  to  tolerate  the  necessary  direct  contact  with  intestinal  contents. 

PLASTIC   ANASTOMOSIS    BETWEEN  THE  BILIARY  PASSAGES 
AND  THE  GASTRO-INTESTINAL  CANAL. 

V.  Stubenrauch's  Methods. — ^Very  rare  cases  occasionally  arise  in  which 
owing  to  a  small  size  of  gall-bladder,  adhesions  in  the  operative  territory,  im- 
mobility of  the  omentum  (e.  g.,  because  of  herniae,  etc.)  it  is  impossible  to  per- 
form any  of  the  ordinary  direct  anastomoses  between  the  gall-bladder  or  ducts 
and  the  alimentary  canal,  and  yet  it  is  absolutely  necessary  to  short  circuit  an 
obstructed  duct. 

V.  Stubenrauch  ("Archiv  fiir  klin.  Chir.,"  Ixxix,  1015)  endeavored  to  solve 
the  above  puzzle  in  a  case  of  chronic  pancreatitis  with  complications  in  the 
following  fashion:  At  a  previous  operation  the  shrunken  gall-bladder  and 
the  common  duct  were  both  drained,  leaving  a  fistula  leading  from  the  skin 
to  the  duct. 

Method  I. — Make  an  incision  through  the  skin  around  the  fistulous  orifice 
Separate  the  fistulous  tract  from  its  surroundings,  leaving  it  connected  with  the 
common  duct  like  a  vermiform  appendix.  Make  an  incision  into  a  convenient 
portion  of  the  stomach  or  duodenum  and  implant  the  distal  end  of  the  fistulous 
tract  into  this.  In  v.  Stubenrauch's  case  the  implantation  into  the  duodenum 
caused  narrowing  of  the  pylorus,  so  gastro-enterostomy  was  done.  Result 
was  failure  due  to  necrosis  of  fistulous  tract. 

Method  II. — Expose  the  openings  in  gall-bladder  and  common  duct. 
Pack  the  common  duct  with  gauze  and  see  if  the  bile  will  flow  into  the  gall-blad- 
der; if  it  will,  use  the  gall-bladder  for  the  anastomosis;  if  it  will  not,  then  use  the 
duct  for  this  purpose.  Expose  the  duodenum  and  pyloric  portion  of  the  stomach. 
From  the  duodenum  and  stomach  reflect  a  flap  with  pedicle  above,  about  i 
inch  wide  and  long  enough  to  reach  without  tension  to  the  opening  in  the  gall- 
bladder or  duct.  This  flap  consists  of  all  the  coats  of  the  viscus  (peritoneal, 
muscular  and  mucous)  (Fig.  553),  Turn  the  flap  upwards.  Occlude  the  open- 
ing in  the  common  duct  by  laying  the  serous  surface  of  the  flap  over  it.     Unite 


STUBENRAUCH. 


475 


the  distal  end  of  the  flap  to  the  opening  in  the  gall-bladder  with  a  few  catgut 
sutures.  Close  the  wound  in  the  stomach  and  duodenum,  leaving  room  for 
a  drainage-tube  at  the  base  of  the  flap.  Introduce  a  drain  between  the  gut  and 
the  gall-bladder.     Partially  close  the  external  wound.     Pack  and  drain. 

Restdt. — Complete    immediate    success.     About    six    months    afterwards 
there  was  slight   and   temporary   evidence  of 
local  trouble. 

V.  Stxibenrauch  suggests  an  improvement 
of  Method  II  and  also  an  alternate  procedure. 

Method  III. — Make  the  gastro-duodenal 
flap  as  above,  but  unite  its  lateral  edges  over  a 
drainage-tube  (Fig.  554)  so  as  to  form  a  tube 
lined  with  mucous  membrane.  Unite  the  free 
end  of  the  flap  to  the  opening  in  the  gall- 
bladder (or  in  the  common  duct  as  the  case 
may  demand)  (Fig.  555).  Make  a  small  open- 
ing into  the  duodenum  a  short  distance  distal 
to  the  flap  and  through  this  make  the  end  of 

the  drainage-tube  emerge.  Unite,  with  sutures,  two  folds  of  duodenal  wall 
over  the  drainage-tube  for  a  short  distance  exactly  as  in  Witzel's  operation 
for  gastrostomy  (Fig.  555).  Bring  the  end  of  the  drainage-tube  out  through 
the  abdominal  wound.  Close  the  wound  in  the  stomach  and  duodenum. 
Pack  and  drain  the  operative  area.  Close  the  excess  of  abdominal  wound. 
By    this    method    drainage   by    a    rubber    tube   is   provided   from   the   gall- 


FiG.  553. 


Fig.  554. 


Fig.  555. 


bladder  (or  common  duct)  through  the  new-formed  bile-duct,  through  the 
duodenum,  through  the  duodenal  wall  by  an  oblique  canal  out  to  the  skin. 
When  repair  is  complete  the  tube  is  easily  drawn  out  and  the  oblique  duodenal 
fistula  quickly  closes.  If  any  stenosis  is  threatened  by  the  operation  a  gastro- 
enterostomy must  be  done.* 

*  It  will  probably  be  wise  to  perform  a  gastro-enterostomy  in  any  of  these  complicated 
plastic  operations  because  there  is  certain  to  be  some  stenosis  and  if  any  of  the  sutures  cut 
loose  there  will  be  a  fistula  which,  even  if  only  temporary,  will  permit  of  the  escape  of  the 
gastric  contents  and  lead  to  starvation. 


476 


OPERATIONS    ON   THE   BILIARY   PASSAGES. 


Method  IV. — A  biliary  fistula  is  present.  It  is  believed  that  any  ordinary 
method  of  cholecystenterostomy  is  impossible.  It  is  desired  to  make  the 
cutaneous  opening  of  the  fistula  empty  itself  into  the  intestine. 

Open  the  abdomen  immediately  to  the  right  of  the  middle  line.  Choose 
a  freely  mobile  loop  of  small  intestine  (one  which  may  be  made  to  reach  the 
region  of  the  fistula).  Divide  the  upper  end  of  this  loop  and  anastomose  the 
open  end  of  the  proximal  gut  to  the  side  of  the  lower  portion  of  gut  at  a  point 
about  41/2  inches  below  the  line  of  section  (Fig.  556).  Make  an  incision 
through  the  skin  alone,  immediately  below  the  biliary  fistula.     Introduce  a 


Fig.  556. 
A.  Anastomosis  between  end  upper  segment  gut  and  side  lower  segment.     F.  Biliary 
fistula  and  incision  through  which  forceps  is  passed  subcutaneously  to  grasp  and  pull  up  to  JF 
the  segregated  portion  of  lower  segment  of  gut  I,. 


forceps  into  this  wound  and  burrow  a  canal  between  the  skin  and  aponeurosis 
down  to  the  laparotomy  wound.  With  the  forceps  pull  the  end  of  the  lower 
segment  of  gut  (temporarily  closed  by  a  ligature)  through  the  subcutaneous 
tunnel  and  unite  it  to  the  cutaneous  opening  of  the  biliary  fistula.  (It  may  be 
necessary  to  mobilize  the  end  of  the  fistula  slightly.)  Close  the  laparotomy 
wound,  being  careful  not  to  constrict  the  portion  of  gut  where  it  passes  through 
the  deep  structures  of  the  belly-wall.  It  might  be  wise  to  supplement  the  long- 
itudinal laparotomy  wound  by  a  small  transverse  incision  through  the  rectus 
and  aponeurosis  at  the  point  where  the  segment  of  gut  passes  through  these 
structures. 

The  author  used  this  method  in  one  case  (reported  by  Sutton,  "Annals  of 


INDICATIONS.  477 

Surg.,''  Sept.,  1910).     The  segment  of  intestine  passing  under  the  skin  to  the 
fistula  retained  its  vitality  but  acted  as  a  faecal  fistula. 

These  methods  of  v.  Stubenrauch  have  been  suggested  for  certain  rare  and 
very  difficult  cases.  Only  one  of  the  methods  has  been  used  \\ith  success. 
They  are  described  here  as  they  are  worthy  of  consideration  and  may  be  help- 
ful in  an  emergency. 

INDICATIONS  FOR  AND  CHOICE  OF  OPERATION. 

It  is  undoubtedly  true  that  in  at  least  one-half  of  all  cases  of  gall-stone 
disease  in  which  diagnosis  has  been  made,  an  apparent  cure  may  result  from 
medicinal  treatment.  Scientifically  such  a  "cure"  is  generally  merely  apparent, 
as  the  calculi  remain  in  situ,  but  are  at  rest  and  give  rise  to  no  evident  trouble. 
The  patient  considers  himself  well,  but  he  is  always  exposed  to  relapse,  and 
the  continued  presence  of  the  stones  is  to-day  believed  to  be  conducive  to  malig- 
nant disease.  Some  surgeons  believe  that  every  case  of  gall-stone  disease 
ought  to  be  submitted  to  early  operation.  Winiwarter  was  the  first  to  pro- 
mulgate this  dictum  and  Riedel  takes  much  the  same  ground.  W.  J.  Mayo 
says  that  the  successful  passage  of  the  calculus  per  vias  naturales  is  not  a  con- 
traindication but  a  positive  indication  for  operation,  as  there  are  always  more 
calculi  to  follow,  and  the  next  ones  may  become  impacted  in  the  common  duct, 
thus  necessitating  a  grave  instead  of  a  safe  operation.  Few  modern  surgeons 
advise  much  loss  of  time  before  operation  is  decided  on.  In  the  writer's  ex- 
perience there  have  been  a  number  of  cases  where  the  symptoms  were  ap- 
parently trifling,  and  yet  exploration  showed  advanced  disease.  There  is  great 
difficulty  and  danger  in  operating  upon  many  of  the  old  cases;  adhesions  and 
contractions  alter  the  anatomy  most  confusingly,  and  all  conceivable  difficulties 
arise.  Early  operation,  before  the  common  duct  is  involved,  is  easy,  and  on 
the  whole  very  safe. 

Mr.  Robson  ("Diseases  of  Gall-bladder  and  Bile-ducts,"  ed.  1901)  gives 
the  following  indications  for  the  performance  of  cholecystostomy:  "(i)  In  all 
cases  where  the  gall-bladder  is  sufficiently  large  to  permit  of  drainage,  after 
gall-stones  have  been  removed  from  the  gall-bladder  or  ducts.  (2)  In  cases 
where  there  are  gall-stones  in  the  ducts,  but  the  patient  is  too  ill  to  bear  a  pro- 
longed operation,  the  gall-stones  being  deliberately  left  for  treatment  by  some 
solvent  solution.  (3)  In  empyema  of  the  gall-bladder,  where  the  viscus  is  not 
too  much  disorganized  to  be  permitted  to  remain.  (4)  In  certain  cases  of 
chronic  catarrh  of  the  gall-bladder  or  bile-ducts.  (5)  In  infective  and  in  sup- 
purative cholangitis.  (6)  In  obstruction  of  the  ducts  due  to  hydatid  disease. 
(7)  In  dropsy  of  the  gall-bladder.  (8)  In  idiopathic  rupture,  or  laceration  or 
gunshot  injury  of  the  gall-bladder  or  ducts.  (9)  In  cases  of  choledochotomy, 
in  order  to  avoid  tension  in  the  sutured  duct.  (10)  In  certain  cases  of  obstruc- 
tive jaundice  dependent  on  malignant  tumor  which  is  occluding  the  ducts;  but 
in  these  cases  the  increased  danger  must  be  borne  in  mind.      (11)  In  some 


478  OPERATIONS    ON   THE    BILIARY   PASSAGES. 

cases  of  phlegmonous  cholecyslits  or  gangrene,  where  the  patient  is  too  ill  to 
bear  cholecystectomy."  To  these  may  be  added  a  twelfth  indication,  viz., 
obstruction  of  the  ducts  from  chronic  pancreatitis. 

In  discussing  the  treatment  of  interstitial  pancreatitis,  Robson  ("Surg.,  Gyn., 
Obstetrics,"  Jan.  1908)  writes: 

"This  brings  into  prominence  the  undesirability  of  removing  the  gall-blad- 
der as  a  routine  procedure  in  operating  for  gall-stones,  for  unless  it  is  seriously 
damaged  or  ulcerated,  or  is  the  seat  of  malignant  disease,  or  unless  there  is 
ulceration  or  stricture  of  the  cystic  duct,  removal  is  quite  unnecessary.  I  think 
it  better  practice  to  drain  it  simply  and  not  to  perform  cholecystectomy,  since 
on  some  future  occasion,  should  trouble  develop  in  the  deeper  ducts  or  in  the 
pancreas,  and  the  gall-bladder  be  absent,  it  will  be  impossible,  with  few  excep- 
tions, to  short-circuit  the  obstruction.  Moreover,  after  cholecystotomy  gall- 
stones have  no  greater  tendency  to  reform  than  they  have  after  cholecystectomy, 
and  should  cholelithiasis  again  develop,  it  will  be  in  the  common  duct,  a  much 
more  serious  position  than  if  in  the  gall-bladder." 

Cholecystectomy  "is  contraindicated  in  all  cases  of  non-patency  of  the  com- 
mon duct,  and  it  should  not  be  resorted  to  under  the  idea  that  it  vnll  prevent 
the  formation  of  gall-stones,  as  calculi  may  form  in  the  bile-duct,  within  the 
liver,  or  below  it." 

Roswell  Park  goes  further  than  most  surgeons,  and  advocates  the  excision 
of  all  diseased  gall-bladders  on  the  same  principle  that  leads  to  the  removal  of 
the  vermiform  appendix  when  diseased.  It  is  certainly  true  that  all  experienced 
surgeons  are  becoming  more  and  more  radical  and  are  extending  the  indications 
for  cholecystectomy  at  the  expense  of  those  for  cholecystostomy.  In  a  goodly 
number  of  cases  where  the  gall-bladder  has  been  removed  on  account  of  great 
inflammatory  thickening  of  its  walls  histologic  examination  has  shown  it  to  be 
the  seat  of  unsuspected  primary  carcinoma.  This  fact  is  the  greatest  incentive 
to  more  frequent  cholecystectomy. 

C.  A.  McWilliams  ("Presbyterian  Hospital  Reports,"  N.  Y.,  1906)  in  a  care- 
ful analysis  of  the  results  and  after-results  of  186  operations  upon  the  liver  and 
gall  passages  finds  the  immediate  danger  of  cholecystectomy  to  be  1.5  per  cent, 
greater  than  that  of  -ostomy,  but  that  the  permanent  results  of  the  -ectomy  are 
very  much  better  than  those  of  the  -ostomy. 

The  author  believes  that  cholecystostomy  is  generally  preferable  in  the 
hands  of  most  surgeons. 

The  question  is  often  asked,  Are  gall-stones  liable  to  form  again  after  they 
have  been  removed  by  any  of  the  above  operations?  The  experience  of  Kehr, 
Robson,  the  Mayos,  Riedel,  and  others,  an  experience  amounting  to  several 
thousands  of  cases,  teaches  that  if  the  calculi  have  been  all  removed  there  is  no 
recurrence.  In  the  hands  of  less  experienced  operators  apparent  recurrences 
crop  up,  but  these  are  usually  cases  of  stones  overlooked  in  the  original  opera- 
tion. The  younger  practitioners  must  remember  that  operation  is  not  directed 
merely  against  the  gall-stones  themselves,  but  against  the  infective  processes 


ECHINOCOCCIC   CYSTS.  479 

which  give  rise  to  them  and  against  the  complications  which  they  occasion. 
The  author  remembers  well  one  case  in  which  a  complete  cure  attended  the 
purely  medicinal  treatment  of  gall-stone  disease,  but  the  patient  succumbed 
to  the  remote  results  of  the  lithiasis,  viz.,  an  extensive  adhesive  peritonitis 
causing  obstruction  of  the  first  portion  of  the  duodenum.  Operated  upon 
early,  this  case  would  have  been  easily  cured;  a  late  and  compulsory  operation 
was  fatal. 

The  indications  for  cholecystenterostomy  have  been  sufl5.ciently  described 
in  earlier  paragraphs. 

COLOHEPATOPEXY  OR  COLON  SUBSTITUTION. 

E.  W.  Andrews  ("  Journ.  Am.  Med.  Assoc,  "Sept.  i6,  1905)  notes  the  severe 
gastric  disturbances  which  follow  wide  adhesion  between  the  liver  and  the 
anterior  surface  of  the  stomach.  If  these  adhesions  are  separated  they  neces- 
sarily reform.  Andrews  endeavors  to  arrange  matters  so  that  where  they 
do  reform  they  will  be  harmless. 

Step  I. — Exposure  through  a  free  right  rectus  incision. 

Step  2. — Note  the  shape,  position  and  mobility  of  the  stomach.  Usually 
numerous  short  bands  or  a  broad  adhesion  will  be  seen  between  the  liver  and 
a  large  part  of  the  pyloric  end  of  the  stomach.  Divide  or  separate  the  ad- 
hesions at  the  expense,  if  necessary,  of  the  liver  rather  than  of  the  stomach.  In- 
spect the  patency  of  the  pylorus  by  passing  the  finger  through  it  in  the  usual 
fashion. 

Step  3. — -\11  adhesions  having  been  freed  and  the  stomach  being  in  normal 
position,  pull  upwards  the  transverse  colon  and  with  it  some  omentum.  Thrust 
these  into  the  space  between  the  liver  and  pylorus.  Stitch  the  colonic  omentum 
to  the  gastro-hepatic  ligament.  The  more  loose  omentum  can  be  interposed 
the  better  it  is. 

Andrews  has  had  excellent  results  from  this  colonic  interposition  or  sus- 
pension. 

OPERATION  FOR  ECHINOCOCCIC  CYSTS  OF  THE  ABDOMEN. 

Echinococcic  cysts  are  composed  of  a  structureless  true  capsule  or  wall  on 
the  inner  surface  of  which  there  develop  the  young  heads  of  the  parasites. 
The  cavity  of  the  cyst  is  filled  with  thin  fluid  in  which  lie  numerous  subsidiary 
or  daughter  cysts.  The  whole  cyst  is  surrounded  by  a  firm  connective-tissue 
capsule  developed  from  the  liver  itself.  The  cysts  may  be  single  or  multiple, 
usually  the  former. 

Out  of  18  cysts  operated  on  by  Mabit  the  site  of  disease  was:  right  lobe  liver, 
8;  left  lobe,  3;  spleen,  2;  omentum,  3;  mesentery,  2.  The  liver  being  the  organ 
usually  affected,  the  operations  here  described  will  have  special  reference  to  it. 

Several  methods  of  operating  on  echinococcic  cysts  have  been  recommended, 
but  most  of  them  have  been  discarded  in  favor  of  more  radical  measures. 
Aspiration  is  ineffectual  and  dangerous.     Injection  of  antiseptics — e.  g.,  bi- 


480  OPERATIONS    ON    THE    BILIARY   PASSAGES. 

chloride  of  mecury  or  formalin  solution — is  dangerous  and  indefinite.     The 
best  method  of  treatment  is  enucleation. 

According  to  the  site  of  the  disease  access  is  gained  to  it  by  one  of  two  routes: 

(A)  Abdominal  Route. — When  the  disease  can  be  reached  by  this  route, 
and  it  usually  can,  it  is  the  preferable  one.  Open  the  abdomen  by  a  vertical 
or  oblique  incision  over  the  most  prominent  part  of  the  tumor.  Explore  the 
liver,  etc.,  to  make  sure  of  the  diagnosis,  to  ascertain  whether  the  disease  is 
single  or  multiple  and  to  satisfy  one's  self  as  to  anatomical  relations.  With 
gauze  packs  thoroughly  isolate  the  field  of  operation  from  the  peritoneal  cavity. 
Protect  the  edges  of  the  abdominal  wound  with  gauze.  The  firm  false  capsule 
of  the  cyst  will  usually  show  prominently  on  the  surface  of  the  liver.  Seize 
the  false  capsule  with  a  stitch  or  a  volsellum.  With  a  trocar  and  cannula  empty 
the  cyst  of  its  fluid  contents,  thus  rendering  its  walls  flaccid.  Pull  the  cyst- 
wall  as  far  as  possible  out  through  the  abdominal  wound  and  incise  it  freely. 
With  fingers,  strips  of  gauze,  and  salt  solution  gently  evacuate  all  daughter 
cysts.  If  possible,  peel  the  true  cyst-wall  from  the  false  fibrous  capsule,  but 
do  not  endeavor  to  excise  the  latter. 

Prepare  a  rubber  tube  by  surrounding  it  with  a  few  layers  of  gauze  and  cover 
the  gauze  with  rubber  tissue.  Introduce  this  "dressed  tube"  into  the  cyst, 
and  with  plain  catgut  suture  the  opening  in  the  cyst  around  and  to  the  tube. 
Cleanse  the  field  of  operation  and  remove  the  gauze  pads  from  the  peritoneal 
cavity.  Suture  the  cyst-wall,  around  the  drainage-tube,  to  the  parietal  perit- 
oneum.    Close  the  excess  of  abdominal  wound. 

If  secondary  cysts  are  present  and  lie  close  to  that  first  opened,  they  may  be 
penetrated  from  it.  Sometimes  several  cysts  may  require  to  be  opened  through 
several  abdominal  incisions.  The  advantage  of  sewing,  with  catgut,  the  open- 
ing in  the  cyst  around  and  to  the  drain  is  that  all  leakage  into  the  belly  is  abso- 
lutely avoided.  The  catgut  remains  effective  until  union  is  so  far  advanced 
that  there  is  no  danger  of  the  peritoneum  becoming  soiled. 

Some  surgeons  perform  the  above  operation  in  two  stages.  At  the  first 
operation  they  expose  the  diseased  portion  of  liver,  pack  the  wound,  and  wait 
ten  days  or  more  for  adhesions  to  form  and  protect  the  peritoneum.  At  the 
second  sitting  they  open  the  cyst  and  treat  it  as  already  described.  There  is 
practically  no  greater  danger  in  completing  the  operation  at  one  sitting  than  in 
waiting  for  adhesions  to  take  place,  and  if  the  cysts  are  multiple,  the  operation 
in  two  stages  is  entirely  unsuitable. 

The  method  of  treatment  outlined  is  known  as  marsupialization;  its  ob- 
jectionable features  are:  long  convalescence;  the  dangers  of  suppuration,  and 
the  persistence  of  biliary  fistulae.  Marsupialization  is  an  eminently  safe 
operation. 

Bond  suggested  that  the  cyst  cavity  might  be  obliterated  by  means  of  buried 
sutures,  and  the  abdomen  closed  without  danger.  Other  surgeons,  after 
evacuating  all  the  cyst  contents,  advise  filling  the  cavity  with  iodoform  emulsion 
or  with  saline  solution,  and  closing  it  completely  with  sutures.     There  is  too 


ECHINOCOCCIC    CYSTS.  48 1 

much  danger  involved  in  this  method  to  render  it  advisable.  The  experience 
of  John  O' Conor,  Mabit,  and  others  shows  that  the  sutured  false  capsule  of  a 
hydatid  cyst  is  very  prone  to  suppuration,  and  that  Bond's  operation,  however 
modified,  is  exceedingly  dangerous.  Mabit  finds  that  if  much  of  the  cyst-wall 
protrudes  beyond  the  parenchyma  of  the  liver,  spleen,  or  whatever  organ  it 
affects,  such  free  cyst-wall  may  be  excised  and  the  remainder  after  being  thor- 
oughly dried,  may  be  left  with  safety  in  the  belly  cavity.  The  operation  of 
Mabit  is  improper  unless  at  least  1/3  of  the  cyst- wall  is  free,  and  unless  the 
contents  are  sterile  as  regards  pyogenic  organisms. 

(B)  Transpleural  Route. — When  the  disease  is  situated  far  back  on  the 
dorsum  of  the  liver,  presses  into  the  subphrenic  region,  and  cannot  be  con- 
veniently reached  from  in  front,  one  gains  access  to  it  by  the  transpleural  route. 

The  Operation. — Excise  about  three  inches  of  the  eighth  or  ninth  rib  in  the 
anterior  axillary  line.  Suture,  with  catgut,  the  parietal  to  the  diaphragmatic 
pleura.  Of  course,  in  inserting  these  sutures  one  aims  at  uniting  the  two 
pleural  surfaces  alone,  i.  e.,  without  other  tissues,  but  one  never  succeeds  in 
so  doing.  The  stitch,  if  effective,  always  includes  in  its  loop  other  tissues  than 
the  pleura.  Incise  the  diaphragm  and  expose  the  liver.  Pack  gauze  all  around 
the  area  of  liver  to  be  opened.     Treat  the  disease  as  already  described. 


31 


CHAPTER  XLII. 


HERNIA. 


Herniotomy. — Formerly  herniotomy  was  considered  one  of  the  most  beau- 
tiful and  satisfactory  operations  in  surgery;  now,  however,  it  is  rarely  thought  of 
as  a  complete  procedure,  but  merely  as  a  preliminary  to  some  one  of  the  opera- 
tions for  the  radical  cure  of  the  hernia.  Under  the  caption  "herniotomy "it 
will  be  convenient  to  describe  the  methods  of  combating  some  of  the  compli- 
cations met  in  cases  of  irreducible  and  of  strangulated  hernias. 

I.  Incision. — (A)  Inguinal  hernia:  (a)  Bassini's  incision  (page  493).  (b) 
Macewen's  incision  (Fig.  557  and  page  491).     (c)  Any  more  or  less  vertical 


Fig.  557. — {Esmarch  and  Kowalzig.) 


Fig.  558. 


incision  over  the  hernial  swelling  and  following  its  long  axis,     {d)  Ferguson's 
incision  (page  495)- 

(B)  Femoral  hernia:  (a)  Bassini's  (page  487).     (b)  Vertical. 

(C)  Umbilical  and  ventral  hernia:     Vertical  or  transverse  incision. 

2.  The  skin  having  been  divided,  one  picks  up  the  subjacent  tissues  layer 
by  layer  and  divides  them  between  forceps*  (Fig.  558).  By  this  method  the 
hernial  sac  is  soon  reached.  How  may  the  sac  be  recognized?  Bull  says  the 
sac  "may  be  recognized,  first,  by  the  presence  of  the  subperitoneal  fat  im- 
mediately outside  it;  second,  by  its  lead  or  bluish  color;  third,  by  its  gliding  over 
the  contents  of  the  sac  beneath  it. 

While  the  sac  in  inguinal  and  femoral  herniae  is  being  freed  from  its  sur- 
roundings, especially  when  its  neck  is  being  isolated  and  dragged  upon,  it  is 

*  The  layers  spoken  of  are  not  the  layers  described  by  anatomists;  such  are  rarely  recog- 
nized and  never  sought,  but  are  such  thin  sheets  of  tissue  as  happen  to  be  picked  up  by  the 
forceps. 

482 


HERNIOTOMY. 


483 


not  rare  to  pull  the  urinary  bladder  into  the  hernial  canal.  The  bladder  may 
be  recognized  by  its  musculature,  and  must  of  course  be  avoided.  B runner 
("Deutsche  Zeitsch.  fiir  Chir.,"  ci,  p.  562)  has  observed  this  dragging  down 
of  the  bladder  in  44  out  of  775  operations  for  inguinal  and  femoral  hernise. 

Especially  in  a  small  hernia,  the  finding  of  the  sac  is  sometimes  a  matter 
of  difficulty.  Remember  that  the  sac  is  a  protruding  pouch  of  peritoneum, 
hence  to  find  it,  e.  g.,  in  an  inguinal  hernia,  examine  the  internal  abdomi- 
nal ring  and  the  sac  will  always  be  found  as  a  continuation  of  the  parietal 
peritoneum. 

3.  A  portion  of  the  sac  which  is  non-adherent  to  its  contents  is  picked  up  by 
forceps  and  cautiously  opened  with  knife  or  scissors.  The  first  opening  is 
made   exceedingly  small   and   is  cautiously 

enlarged  until  the  finger  can  be  introduced 
and  discover  the  condition  of  the  contents, 
after  which  the  sac  is  widely  opened. 

4.  Examination  in  cases  of  irreducible 
and  strangulated  hernise  almost  always  shows 
stricture  of  the  neck  by  firm  surrounding 
tissues.  Division  of  stricture:  (A)  The  gen- 
eral method  is  to  introduce  the  finger-nail  of 
the  left  fore-finger  into  the  stricture,  the 
back  of  the  finger  being  against  the  hernia, 
keeping  it  out  of  the  way  (Fig.  559).  A  hernia 
knife  is  laid  flat  on  the  palm  of  the  finger  and 

pushed  along  until  its  blunt  nose  has  got  beyond  the  constricting  band. 
The  edge  of  the  knife  is  now  turned  and  pressed  against  the  stricture  in  such  a 
way  as  to  make  a  number  of  small  nicks  instead  of  any  definite  cut.  No  sawing 
motion  should  be  given  to  the  knife  and  its  edge  should  always  be  blunt. 
In  inguinal  hernia  if  these  precautions  are  adhered  to,  it  makes  little  difference 
whether  one  cuts  upwards  and  outwards,  upwards  and  inwards,  or  only  gener- 
ally upwards,  since  such  a  knife,  so  used,  would  be  extremely  unlikely  to 
injure  any  vessel.  Should  any  vessel  be  divided  and  bleeding  occur,  it  is  easy  to 
enlarge  the  Vound  and  ligate  the  bleeding  point.  A  herniotomy  knife,  while 
convenient,  is  not  necessary — its  work  can  be  done  by  a  pair  of  blunt-pointed 
scissors.  (B)  Most  surgeons  now  advocate  the  division  of  the  constricting 
tissues  from  without  inwards,  exacdy  as  the  canal  is  opened  during  a  radical 
operation.     This  is  the  easiest,  safest  and  best  rr.elhod  to  follow. 

5.  Contents  of  the  Sac.—U  the  contents  consist  of  healthy  gut  or  healthy  non- 
adherent or  non-redundant  omentum,  they  are  to  be  reduced  at  once.  If 
adhesions  are  present,  they  must  be  gently  torn  through  or  divided  between 
ligatures.  Sometimes  adhesion  between  gut  and  sac  is  so  firm  that  a  thin 
portion  of  sac  has  to  be  cut  away  and  left  attached  to  the  gut.  If  the  omentum 
is  redundant,  inflamed  or  much  lacerated  from  the  division  of  adhesions  most  of 
it  should  be  removed.     This  is  done  by  placing  a  chain  of  ligatures  across  it 


Fig.  559. — {Esmarch  and  Kowalzig.) 


484 


HERNIA. 


(Fig.  560)  and  cutting  away  the  peripheral  portion  at  a  distance  of  at  least 
one  inch  from  the  ligatures. 

Remove  as  little  omentum  as  possible;  omentum  is  most  valuable. 


Fig.  560.  Fig.  ^6i.—{Guibe.) 

Should  the  gut  be  gangrenous,  it  may  be  dealt  with  in  several  ways: 
(a)  Only  a  small  spot  on  the  free  surface  of  the  gut  is  gangrenous,  the  rest 
of  the  gut  is  healthy.     Invaginate  the  gangrenous  patch  by  a  few  Lembert 


Fig.  562. — -{Veaii.) 

sutures  (Fig.   561).     E.xamine  to  see  if  the  invagination  produces  too  much 
narrowing  of  the  gut. 

If  the  gangrene  affects  all  or  nearly  all  the  circumference  of  the  gut,  but 
affects  little  of  its  long  axis,  use  Summer's  operation. . 


HERNIOTOMY. 


485 


(b)  Gangrene  is  extensive.  Pull  down  healthy  gut  from  beyond  the  strictures 
caused  by  the  constricting  abdominal  opening  (Fig.  562).  Doubly  clamp  both 
the  afferent  and  efferent  loops  of  gut.  If  an  end-to-end  union  is  to  be  made, 
the  clamps  nearest  the  body  must  be  protected  with  rubber  tubing  and  must 
not  crush.  If  a  lateral  anastomosis  is  contemplated,  crushing  forceps  are  best. 
Divide  between  the  forceps.  Ligate  and  divide  the  mesentery.  Remove 
the  excised  gut  and  mesentery. 

With  through-and-through  catgut  sutures,  close  the  ends  of  both  segments 
of  gut  protruding  from  the  clamps.  Insert  a  purse-string  suture  (Fig.  563)  on 
the  body  side  of  each  clamp.  Remove  the  clamps.  Invaginate  the  ends  of 
the  guts,  tighten  and  tie  the  purse-string  sutures.     Unite  the  afferent  and  efferent 


Fig.  563. 


loops  of  gut  by  lateral  anastomosis.  (Instead  of  lateral  anastomosis,  end-to- 
end  or  end-lo-side  anastomosis  may  be  practised.)  If  there  is  doubt  as  to  the 
viabiUty  of  the  gut  or  as  to  the  cleanliness  of  the  field  of  operation  fix  the  united 
segments  of  gut  near  the  wound  in  the  parietes  by  means  of  a  well-placed 
cigarette  or  oiled-silk  drain. 

(c)  The  general  condition  of  the  patient  renders  a  complete  operation  haz- 
ardous. Excise  the  gangrenous  segment  of  gut.  Unite  the  open  ends  of  the 
healthy  gut  to  the  wound,  thus  providing  an  artificial  anus  which  may  be  closed 
subsequently.  This  is  probably  the  safest  plan  for  inexperienced  surgeons  to 
adopt. 

(d)  The  general  condition  of  the  patient  is  poor;  the  temperature  is  about 
normal  or  even  subnormal;  the  pulse  is  120  or  more;  the  abdomen  is  tense  and 
distended.     Relieve  the  constriction,  pull  down  healthy  gut  and  fix  it  to  the 


486  HERNIA. 

wound.  Incise  the  gut  to  obtain  intestinal  drainage.  Do  not  remove  any 
tissue.  Drain  the  whole  wound  freely  and  endeavor  to  keep  the  patient  alive 
by  suitable  food  and  stimulants. 

(e)  In  strangulated  femoral  hernia  it  is  wise  to  recognize  the  fact  that  the 
small  size  of  the  femoral  canal  hinders  or  prevents  the  proper  treatment  of  the 
gut.     One,  therefore,  opens  the  abdomen  immediately  above  Poupart's  liga- 


FiG.  564. — (Guibe.)  FiG.   565. —  (Guibe.) 


ment;  protects  the  belly  cavity  with  pads;  reduces  the  hernia  (working  from 
the  abdominal  side);  excises  the  gangrenous  segment;  repairs  the  bowel;  pro- 
vides drainage  from  below  and  closes  the  abdominal  wound. 

Unless  contraindicated  by  the  weak  state  of  the  patient  or  by  the  necessity 
of  deep  drainage,  herniotomy  ought  always  to  be  followed  by  an  effort  after 
radical  cure.     {Vide  "Special  Operations.") 


566. — (Guibe.)  Fig.   567. — (Guibe.) 


Retrograde  Strangulation  of  Intestine. — When  operating  for  strangulated 
hernia  remember  that  two  portions  of  a  loop  of  intestine  may  protrude  into  the 
sac  but  an  intermediary  portion  of  the  same  loop  may  remain  in  the  abdomen 
(Fig.  568) .  When  this  is  the  case  it  is  quite  possible  for  the  blood-vessels  of  the 
intermediary  portion  to  be  caught  and  obstructed  in  the  hernial  ring,  thus 
causing  gangrene  of  the  intraabdominal  loop  of  gut  while  the  two  portions 
actually  in  the  hernia  remain  unaffected.     In  two  cases  (Lorenz)  the  strangu- 


FEMOR-'VL   HERNIA. 


487 


lation  was  due  not  to  inclusion  in  the  ring  of  the  affected,  but  to  acute  flexion 
of  the  vessels  caused  by  the  dragging  on  them  of  the  two  herniated  seg- 
ments of  intestine.  Of  course  the  intraabdominal  strangulation  demands 
laparotomy. 

SLIDING  HERNIAE. 

Sliding  Hernia. — When  large  intestine  is  present  in  the  hernia  that  part 
of  the  parietal  peritoneum  to  which  it  is  attached  (with  or  without  meson)  may 
slide  down  and  form  part  of  the  sac.  This  must  be  remembered  when  a  portion 
of  large  intestine  appears  to  be  adherent  to  the  sac.  Figs.  564,  565,  566,  567, 
568,  explain  sufhciently  how  the  sac  may  be  used  to  reconstitute  the  meson  and 
protect  the  intestinal  blood-supply. 

Bull  and  Coley  have  had  relapses  in  one  out  of  eight  cases  of  sliding  hernia 
operated  on  by  them.     Fiaschi  ("Australasian  Med.  Gaz.,"  Nov.  20,   1907) 


iGidbe.) 


Fig.  569. 


has  had  considerable  experience  with  sliding  hernia  and  considers  relapse  to 
be  due  to  "the  vicious  habit  of  sliding  down  acquired  by  that  portion  of  intestine 
which  formed  the  sliding  hernia." 

To  counteract  the  above  tendency  he  supplements  the  ordinary  operation 
on  the  hernia^by  anchoring  the  offending  portion  of  the  colon  to  the  belly-wall 
(colopexy)  through  a  muscle-splitting  (gridiron)  incision. 


FEMORAL  HERNIA. 

Radical  Cure. — Undoubtedly  Bassini's  method  of  operation  is  one  of  the 
best,  although  it  may,  perhaps,  be  improved  by  adding  to  it  Macewen's  method 
of  utilizing  the  sac  to  form  an  intra-abdominal  pad. 

Step  I. — Make  an  incision  3  inches  long,  parallel  to  and  below  Poupart's 
ligament  (Fig.  570).  The  centre  of  this  incision  corresponds  to  the  centre  of 
the  hernial  swelling.  Divide  the  tissues  layer  by  layer  between  forceps  until 
the  sac  is  reached.     The  superficial  fascia  may  be  surprisingly  thick  and  fatty. 

Step  2. — By  blunt  dissection  free  the  sac  from  its  surroundings. 


488 


HERNIA. 


Step  3. — Open  the  sac  and  reduce  its  contents.  (For  treatment  of  compli- 
cations see  page  483.) 

Step  4. — (A)  Bassini,  having  separated  the  sac  from  its  surroundings  up  to 
its  junction  with  the  parietal  peritoneum  (of  which  it  is  a  mere  process),  trans- 
fixes and  ligates  it  at  this  point  and  cuts  away  the  peripheral  portion.  Many 
surgeons  close  the  external  wound  and  terminate  the  operation  at  this  point. 

(B)  Macewen,  having  separated  all  the  sac  from  its  surroundings,  pushes 
his  finger  through  the  femoral  opening  outside  the  sac  and  separates  the  parietal 
peritoneum  from  the  parietes  for  a  distance  of  3/4  inch   above  the  opening. 

He  then  treats  the  sac  exactly  as  in  his  oper- 
ation for  inguinal  hernia,  making  it  into  an 
intra-abdominal  pad.     (See  page  492.) 

Step  5. — Make  a  careful  survey  as  to  the 
position  of  Gimbernat's  ligament,  Poupart's 
ligament,  the  plica  falciformis,  and-  the 
pectineal   fascia.      Retract   the  plica  falci- 


FlG.  570. 


Fig.  571. 


formis  upwards  and  outwards.  With  a  full  curved  needle  introduce  the 
suture  A-A  (Fig.  571)  through  the  inferior  and  posterior  part  of  Poupart's 
ligament  and  the  pectineal  fascia  close  to  the  pubic  spine.  About  1/4  inch 
external  to  a-a  introduce  the  suture  b-b.  In  the  same  way  the  suture  c 
is  introduced  and  ought  to  lie  about  1/2  inch  internal  to  the  femoral  vein. 
The  sutures  a,b,  and  c  are  left  for  the  present  without  being  tied. 

Step  6. — The  plica  falciformis  is  stitched  to  that  portion  of  the  pectineal 
fascia  which  normally  forms  the  posterior  wall  of  the  femoral  funnel.  The 
insertion  of  these  stitches  is  shown  in  Fig.  572  (x-x,  y-y,  z-z). 

Step  7. — The  sutures  a-a,  b-b,  c-c,  are  tied.  This  approximates  Poupart's 
ligament  to  the  fascia  covering  the  horizontal  ramus  of  the  pubis.  The  sutures 
x-x,  Y-Y,  z-z  are  tied.  This  slides  the  plica  falciformis  inwards  to  its  normal 
position  or  to  an  exaggeration  of  its  normal  position,  and  completes  the  closure 
of  the  canal.  The  long  saphenous  vein  is  left  to  dip  unmolested  under  the  in- 
ferior end  of  the  plica  falciformis.  (N.  B. — Sutures  a-a,  b-b,  c-c  close  the 
abdominal  opening  into  the  femoral  canal.  Sutures  x-x,  y-y,  z-z  close  the  canal 
itself. 


FEMORAL   HERNIA. 


489 


Step  8. — Closure  of  the  skin-wound. 

Roux's  Operation. — The  hernia  is  exposed  and  its  sac  ligated  and  excised 
as  in  the  Bassini  operation.  The  peculiar  feature  of  the  operation  is  the  method 
of  closing  the  femoral  canal,  as  follows:  Pass  a  metal  staple  obliquely 
through  Poupart's  ligament  over  the  crural  canal  to  the  inside  of  the  femoral 
vessels,  carefully  avoiding  the  vein  (Fig.  573).  Gendy  hammer  the  points  of 
the  staple  into  the  pubis.  The  staple  or  nail  must  not  be  inserted  too  tightly 
lest  Poupart's  ligament  be  injured.  J.  Crawford  Renton  reports  that  Roux 
has  successfully  used  this  method  in  60  cases  and  he  himself  in  10.  The  super- 
ficial wound  is  closed  in  the  usual  manner. 

Aslett  Baldwin's  Operation  ("Lancet,"  July  21,  igo6).—Step  i. — Expose 
and  fully  isolate  the  hernial  sac.     Reduce  the  hernia. 

Step  2. — Introduce  a  slightly  curved  director  or  dissector  into  the  femoral 
canal  in  front  of  the  sac  and  with  it  dissect  a  path  upwards  between  the  parietal 


Fig. 


Fig.  573. 


peritoneum  and  Poupart's  ligament  to  a  point  about  1/2  inch  above  Poupart's 
Hgament  (Fig.  574).  At  this  point  tilt  the  end  of  the  director  forwards  so  that 
it  can  be  felt  through  the  aponeurosis  of  the  external  oblique.  Make  a  short 
incision  through  the  aponeurosis,  parallel  to  its  fibres  and  protrude  the  director 
through  the  opening. 

Step  3. — Pass  a  forceps  (sinus  forceps  or  haimostat)  along  the  director  from 
above  downwards  (Fig.  575).  Remove  the  director.  Seize  the  distal  end  of  the 
sac  with  the  forceps  and  pull  it  through  the  tunnel  (Fig.  576).  Pull  the  sac  as 
far  as  possible  through  the  opening  in  the  external  oblique;  ligate  the  neck  of 
the  sac. 

Step  4. — Fix  a  stout  stitch  of  catgut  to  the  fundus  of  the  sac.  Leave  both 
ends  of  the  stitch  long.  Pass  one  end  of  the  stitch  several  times  through  the 
sac  (Fig.  577)  and  then  make  it  take  the  following  course — through  the  opening 
in  the  aponeurosis  of  the  external  oblique,  through  the  neck  of  the  sac  down  to 
the  horizontal  ramus  of  the  pubis  which  it  must  hug,  then  downwards  and  for- 
wards through  the  pectineus  muscle  and  fascia  to  emerge  through  the  inner 
part  of  the  saphenous  opening  (Fig.  577). 

Step  5. — Pulling  on  the  thread,  push  the  sac  back  through  the  opening  in  the 


490 


HERNIA. 


aponeurosis  until  it  is  lost  to  sight.     The  tucking  away  of  the  sac  may  be  aided 
by  the  use  of  a  stout  probe  or  a  forceps. 

The  sac  now  lies  curled  up  behind  Poupart's  ligament;  from  it  one  end  of 
a  suture  hangs  out  through  the  small  opening  in  the  aponeurosis;  the  other  end 


Fig.  574. — -{Baldwin.) 


Fig.   576. — (Baldwin.) 


Fig.   575. — {Baldwin.) 


J6 

Fig.   577. — {Baldwin.) 


of  the  suture  passes  through  the  tissues  on  the  deep  side  of  the  femoral  canal 
(Fig.  578).  Tie  the  two  ends  of  the  suture  together;  this  closes  the  femoral 
canal. 

Baldwin's  operation  seems  better  suited  to  the  female  than  to  the  male 
because  of  anatomical  considerations. 


INGUINAL   HERNIA. 


491 


RADICAL  CURE  OF  INGUINAL  HERNIA. 

The  older  operations  for  the  radical  cure  of  inguinal  hernia  were  faulty  and 
unsuccessful  because  they  were  based  on  the  idea  that  the  hernia  escaped  from 
the  abdomen  through  a  ring,  and  that  if  the  edges  of  the  ring  were  brought  to- 
gether, a  cure  would  be  obtained.  The  scar  left  by  such  edge-to-edge  closure 
of  the  ring  can  never  offer  any  great  opposition  to  recurrence  of  the  hernia. 
All  the  good  modern  operations  are  based  on  the  idea  that  the  hernia  has  origi- 
nally passed  through  a  more  or  less  oblique  canal,  which  it  has  converted  into  a 
ring-like  opening,  and  that  to  effect  a  cure  it  is  necessary  to  reverse  the  process 
and  convert  the  ring  into  an  oblique  canal — narrower  and  more  resistant  to 
abdominal  pressure  than  the  original  canal  had  been.  All  operations  which 
carry  out  the  above  principle  are  successful  in  effecting  cures. 


Fig.  578. — (Bald-win.) 


Fig.  579.- — {Esmarch  and  Kowalzig.) 


Macewen's  Operation. — i .  Make  an  oblique  incision  about  3  inches  in  length 
over  the  external  abdominal  ring.  Practically  a  good  rule  is  to  begin  the  cut 
I  inch  above  and  to  the  outer  side  of  the  upper  limit  of  the  hernial  swelling  and 
continue  the*incision  downwards  and  inwards  over  the  hernial  neck.  Expose 
the  upper  part  of  the  sac  of  the  hernia. 

2.  By  blunt  dissection  free  the  sac  from  its  surroundings  and  from  the  sper- 
matic cord,  which  lies  posteriorly.     This  must  be  done  thoroughly. 

3.  Reduce  the  contents  of  the  sac  and  then  open  and  inspect  it.  It  is  often 
necessary  to  open  the  sac  before  the  hernia  can  or  ought  to  be  reduced.  (For 
treatment  of  complications  see  page  483.) 

4.  Pass  the  finger  outside  the  sac  through  the  opening  of  the  parietes 
and  separate  the  peritoneum  (of  which  the  sac  is  a  mere  continuation)  from 
the  parietes  for  a  space  of  3/4  inch  on  every  side  of  the  opening  (Fig.  579). 

5.  Should  the  sac  be  too  voluminous,  cut  off  its  distal  end,  which  may 
be  removed  or  left  in  the  scrotum.  Every  time  it  is  necessary  to  make  an 
incision  in  the  sac  the  position  of  the  cord  should  be  ascertained. 

6.  A  stitch  of  chromicized  catgut  is  taken  through  the  distal  extremity 


492 


HERNIA. 


of  the  sac,  which  is  now  hanging  loosely  through  the  abdominal  wall  (Fig. 
580),  and  is  there  tied.  The  long  end  of  the  suture  is  passed  three  or  four 
times  from  side  to  side  through  the  sac,  so  that  when  pulled  upon  it  throws 
the  sac  into  folds.  The  loose  end  of  the  thread  is  threaded  on  a  Macewen 
hernia  needle.  The  needle,  guided  by  the  finger,  is  passed  up  external  to 
the  sac  through  the  abdominal  opening,  and  thrust  outwards  through  the 
whole  thickness  of  the  parietes  (with  the  exception  of  peritoneum  and  skin) 
(Fig.  580).  If  the  thread  is  now  pulled,  the  sac  will  be  reduced  into  the  belly 
cavity  (external  to  the  peritoneum),  and  will  form  a  firm,  puckered-up  pad 
lying  between  the  peritoneum  and  the  parietes  (Fig.  581).  The  end  of  the 
thread  is  caught  by  a  hemostat  and   temporarily  thrown  aside. 


Fig.  581. 


7.  A  Macewen  hernia  needle  is  passed  through  the  conjoined  tendon 
from  without  inwards,  and  its  point,  guided  by  the  finger  in  the  abdominal 
opening,  is  carried  upwards  for  about  3/4  of  an  inch  and  once  more  passed 
through  the  conjoined  tendon,  this  time  from  within  outwards  (Fig.  582  a  and 
b).  By  this  means  a  strong  chromicized  catgut  thread  is  placed  in  position 
through  the  inner  wall  of  the  ring. 

8.  The  lower  end  of  the  suture  is  now  threaded  on  an  appropriate  needle 
and  passed  through  Poupart's  ligament  from  within  outwards  a  short  distance 
above  the  spermatic  cord  (Fig.  582  c).  The  upper  end  of  the  suture  is  passed 
from  within  outwards  through  the  aponeurosis  of  the  external  oblique.  We 
now  have  a  single  thread  which  takes  the  course  seen  in  Fig.  582  d.  If  one 
pulls  upon  the  ends  of  the  suture,  the  tissues  external  and  inferior  to  the  open- 
ing (viz.,  Poupart's  ligament  and  the  aponeurosis  of  the  external  oblique) 
must  slide  over  those  internal  and  superior  (viz.,  the  conjoined  tendon), 
and  when  the  suture  is  firmly  tied,  the  obliquity  of  the  inguinal  canal  is  re- 


INGUINAL  HERNLA.. 


493 


stored.  The  anterior  surface  of  the  conjoined  tendon  is  in  apposition  with 
the  posterior  surface  of  Poupart's  Hgament.  Before  the  suture  is  definitely 
tied  the  spermatic  cord  is  examined  lest  too  much  pressure  be  exerted  on  it. 
9.  The  end  of  the  suture  used  for  puckering  the  sac  is  now  pulled  tight 
and  fixed  in  the  belly-wall  subcutaneously. 


Fig.  582. —  (Esmarcli  and  Kowalzig.) 

10.  The  skin-wound  is  closed. 

Macewen  makes  use  of  special  handled  needles,  but  these  are  not  really 
necessary.  The  author  has  frequently  used  common  full-curved  needles 
grasped   in    a   needle-holder   and   found   them   absolutely   satisfactory. 

Bassini's   Operation. — i.  An  incision  is  made  parallel  to  and  1/2  inch 


Fig.  583. 


above  Poupart's  ligament.     It  begins  external  to  the  region  of  the  internal 
abdominal    ring   and   ends   internal   to    the   external    ring. 

2.  A  firm  aponeurotic  sheet  (aponeurosis  of  external  oblique)  covering 
the  hernia  is  exposed  and  divided  in  the  direction  of  the  wound  with  scissors 
or  on  a  director   (Fig.  583).     Thus  are  formed  a  superior  and  inferior  apo- 


494 


HERNIA. 


neurotic  flap.     The  superior  flap  is  separated  from  the  subjacent  tissues  for 
a  distance   of    i    or    i    1/2   inches. 

3.  The  hernial  sac  now  lies  exposed  from  its  peritoneal  origin  to  the  point 
where  it  disappears  into  the  scrotum,  and  is  recognized  according  to  the  rules 
described  on  page  482.  With  blunt  dissection  the  sac  is  separated  from  its 
surroundings  and  from  the  spermatic  cord.  This  must  be  done  thoroughly 
and  carefully.  The  sac  should  be  opened  and  its  contents  reduced  or  treated 
as  described  on  page  483. 

4.  Downward  traction  being  exerted  on  the  sac,  its  neck  is  transfixed  and 


Fig.  584. 


Fig.  585. 


ligated  as  high  up  as  possible,  and  the  distal  portion  cut  off.  The  stump 
should  retract  into  the  belly  cavity  and  be  lost  to  sight.  Sometimes  the  neck 
of  the  sac  is  so  bulky  or  of  such  a  shape  that  ligation  is  impossible.  In  these 
cases  the  neck  of  the  sac  is  sewed  up  and  the  distal  portion  removed.  By 
whatever  method  the  neck  is  closed  and  divided,  special  attention  ought  to  be 
paid  to  the  position  of  the  spermatic  cord,  as  this  important  structure  has 
frequently  been  injured.  Separation  of  the  sac  from  its  surroundings  has 
freshened  all  the  tissues  so  that  if  placed  in  apposition  they  will  unite. 

5.  The  spermatic  cord  is  raised  from  its  bed  and  held  out  of  the  way  by 

a  blunt  hook.  Review  of  the  wound  now 
shows  that  its  upper  edge  consists  of  three 
layers:  (A)  A  deep  thick  layer,  marked 
muscular  flap  (Fig.  584).  (Internal  obHque 
and  transversalis  muscles,  transversalis 
fascia,  and  external  margin  of  the  rectus.) 
jTjg     35  (B)    Superior  aponeurotic  flap.     (Aponeu- 

rosis of  external  oblique.)  (C)  The  skin. 
The  lower  edge  of  the  wound  consists  of  the  deep  layer  of  Poupart's  ligament  on 
which  the  spermatic  cord  normally  lies,  the  inferior  aponeurotic  flap,  and  the  skin. 

6.  A  suture  is  now  passed  through  the  muscular  flap  (Figs.  584,  585) 
close  to  the  exit  of  the  cord  from  the  abdomen,  and  unites  it  to  the  deeper 
layer  of  Poupart's  ligament.  This  suture  must  be  so  placed  as  to  close  the 
wound  beside  the  cord,  but  yet  not  interfere  with  its  circulation.  Some  sur- 
geons place  a  suture  external  to  the  cord  at  the  point  marked  x.  Fig.  585.  This 
is  important.  The  whole  edge  of  the  muscular  flap  (Figs.  584,  585)  is  stitched 
to  the  deep  layer  of  Poupart's  ligament. 


INGUINAL   HERNIA. 


495 


7.  The  cord  is  now  laid  on  the  top  of  the  Hne  of  suture  and  the  superior  and 
inferior  aponeurotic  flaps  united  over  it  (Fig.  586). 

8.  The  skin-wound  is  closed. 

Ferguson's  Operation. — A.  H.  Ferguson  has  noticed  that  a  deficient 
origin  of  the  internal  oblique  and  transversalis  muscles  at  Poupart's  liga- 
ment is  a  fruitful  cause  of  recurrence  after  operations  for  the  cure  of  inguinal 


Fig.  587. — {A.  H.  Ferguson.) 

hernia.  To  expose  and  correct  such  deficiency  he  has  devised  the  follow- 
ing  operation: 

Step  I. — Make  a  semilunar  incision,  with  convexity  upwards,  from  a  point 
in  Poupart's  ligament  i  1/2  inches  below  the  anterior  superior  spine  to  a  point 
on  the  conjoined  tendon  near  the  pubis  (Fig.  587).  Reflect  the  flap  thus 
outlined,  exposing  the  aponeurosis  of  the  external  oblique  and  the  hernia. 

Step  2. — Cut  through  the  external  abdominal  ring  and  intercolumnar 
fascia;  separate  the  longitudinal  fibres  of  the  aponeurosis  of  the  external 
oblique  directly  over  the  inguinal  canal,  far  beyond  the  internal  ring,  over 


496 


HERNIA. 


the  surface  of  the  internal  obUque,  and  up  under  the  skin  to  a  point  nearly 
opposite  the  anterior  superior  spine  (Fig.  587).  This  exposes  all  the  con- 
tents of  the  inguinal  canal,  and  any  deficiency  in  the  origin  of  the  internal 
oblique  and  transversalis  muscles  is  seen. 

Step  3. — Attend  to  the  hernial  contents  and  sac  in  the  manner  already 
described. 

Step  4. — Lessen  the  size  of  the  dilated  internal  ring  by  means  of  a  few 
stitches   (Fig.    588).     Suture   the  internal   oblique  and  transversalis  muscles 


Fig.  588. — {A.  H.  Ferguson.) 

to  the  inner  aspect  of  Poupart's  ligament  and  restore  their  normal  origin 
(Fig.  589).  The  line  of  suture  extends  fully  two-thirds  down  the  ligament. 
Take  care  not  to  split  the  ligament  by  grasping  with  the  needle  the  same  longi- 
tudinal fibres  each  time.  In  this  step  the  Mayos  suture  the  upper  edge 
of  the  wound  in  the  external  oblique  fascia  along  with  the  internal  oblique 
muscle  to  the  inner  aspect  of  Poupart's  ligament  and  then  make  the  lower 
portion  of  the  fascia  (continuous  with  Poupart's  ligament)  overlap  the  line 


AFTER-TREATMENT. 


497 


of  suture  and  fix  it  in  position  by  means  of  a  few  stitches.  Close  the  wound 
in  the  aponeurosis  of  the  external  oblique.  Restore  the  external  abdominal 
ring.     Replace    and    suture    the    semilunar    skin-flap. 

To  the  writer  the  Ferguson  operation  seems  eminently  sane. 

After-treatment. — Bassini  permits  his  patients  to  leave  their  beds  and 
go  to  work  after  the  lapse  of  two  weeks.  Macewen  believes  that  no  wound 
is  firmly  healed  after  such  a  short  time.  When  it  is  possible  to  carry  out  the 
followihg    rules,    they   will    be    found   exceedingly   satisfactory: 


Fig.  589. — (.4.  H.  Ferguson.) 

For  a  period  of  four  weeks  after  operation,  rest  in  bed. 

For  a  period  of  six  weeks  after  operation,  when  the  bowels  are  being  moved, 
the  patient  should  be  in  the  recumbent  posture  so  as  to  avoid  strain  on  the 
wound. 

For  a  period  of  three  months  after  operation  there  should  be  no  hard 
manual   work. 

The   Johns   Hopkins    Operation    for   Hernia. — This   operation   is   the 


498 


HERNIA. 


Fig.   5go. — [Halsled.) 


Fig.  S9^-— (Hal sled.) 


INGUINAL   HERNIA. 


499 


result  of  the  experience  and  ingenuity  of  the  surgical  staff  in  the  Johns  Hopkins 
Hospital.  It  is  based  on  the  original  operation  of  Halsted,  modified  by  him- 
self and  Bloodgood.     ("Johns  Hopkins  Bulletin,"  August,   1903.) 

Step  I. — Divide  the  skin  and  the  aponeurosis  of  the  external  oblique  as 
in  the  Bassini  operation.     Reflect  the  aponeurotic  flaps. 

Step  2. — Split  the  cremaster  muscle  and  fascia  along  a  line  a  little  above 
the  centre  of  the  cord. 

S(ep   3. — Expose  clearly  the  internal  oblique  muscle  beside  the  canal. 

Step  4. — Examine  the  hernia  and  the  cord.  If  the  veins  are  large,  and 
this  is  usually  the  case,  excise  them  with  very  great  care  to  avoid  even  the 
slightest  extravasation  of  blood  into  the  tissues  about  the  smaller  veins  and 


Fig.  592. — {Halsted.) 


about  the  vas  deferens  which  they  accompany.  Do  not  raise  the  vas  deferens 
from  its  bed;  do  not  handle  or  even  touch  it,  if  possible,  lest  thrombosis  of 
its  veins  occur  (Fig.  590).  Ligate  the  veins  as  high  up  in  the  abdomen  as 
possible,  pulling  them  quite  firmly  just  before  the  ligature  (in  a  needle  with 
the  blunt  end  first)  is  passed  between  them.  Ligate  the  lower  portions  of 
the  veins  at  a  point  as  high  above  the  testicle  as  possible,  the  stump  being, 
of  course,  outside  the  external  abdominal    ring. 

Step  5. — Ligate  the  sac  by  transfixion  or  purse-string  suture  at  the  highest 
possible  point.  After  tying  this  suture  thread  its  ends  on  long  curved  needles 
and  pass  them  outwards  under  the  internal  oblique  muscle  to  penetrate  the 
muscle  from  within  outwards  at  two  points  about  5  mm.  (1/8  inch)  apart. 
Tie  the  ligatures.  This  step  dislocates  the  neck  of  the  sac  in  a  manner  es- 
sentially the  same  as  is  recommended  by  Kocher. 

Step  6. — Draw  the  lower  flap  of  cremaster  muscle  and  fascia  up  under 


500 


HERNIA. 


the  internal  oblique  muscle,  and  fix  it  there  by  fine  sutures  which,  having 
engaged  firmly  a  few  bundles  of  the  cremaster,  perforate  the  internal  oblique, 
preferably  where  it  is  becoming  aponeurotic,  and  are  tied  on  the  external 
surface  of  the  latter  (Fig.  591). 


Fig.  593. — (Halsied.) 


Fig.   594. — (Halsted.) 


Step  7. — Stitch  the  internal  oblique  muscle,  mobilized  and  possibly  further 
released  by  incising  the  anterior  sheath  of  the  rectus  muscle  (along  with  its 
conjoined  tendon)  to  Poupart's  ligament  (Fig.  592).  Do  this  in  such  a  manner 
that  the  lower  edge  of  the  internal  oblique  is  tucked  under  Poupart's  ligament. 


INGUINAL   HERNIA. 


501 


Step  8. — Suture  the  aponeurotic  flaps  of  the  external  obhque  by  the  An- 
drews-Halsted   method,   which  makes  them  overlap    (Figs.    593,    594). 

Step   9. — Close  the  skin-wound. 

WTiere  the  hernial  opening  is  very  large  and  the  conjoined  tendon 
atrophied,  a  flap  of  the  anterior  sheath  of  the  rectus  muscle  may  be  reflected 
outwards  and  downwards  and  sutured  to  the  under  surface  of  Poupart's 
ligament  (Fig.  595).  This  flap  of  fascia  aids  in  closing  the  canal  by  the 
usual  means. 

Kirschner  ("Archiv.  fur  klin.  Chir.,"  xcii,  896)  supports  the  line  of  suture 
as  follows:  Make  an  incision  through  the  skin  of  the  thigh  and  expose  a  suffi. 


Fig.   595. — {Halsted.) 


cient  area  of  fascia  lata;  excise  a  strip  of  fascia  lata  longer  than  the  hernial 
wound  and  about  two  to  two  and  one-half  inches  wide;  spread  this  "free" 
fascial  flap  over  the  line  of  suture  closing  the  inguinal  canal  and  suture 
it  there. 

Instead  of  using  a  flap  of  rectus  sheath  to  aid  in  closing  the  inguinal  canal 
when  the  conjoined  tendon  is  insufficient,  Bloodgood  splits  the  outer  margin 
of  the  rectus  sheath  from  the  pubic  insertion  upwards  for  2  inches  (5  cm.). 
The  muscle  bulges  from  the  cut  and  is  sutured  to  Poupart's  ligament. 

En  resume. — The  special  features  of  the  Johns  Hopkins  methods  of  operating  are  : 

1.  Excision  of  the  veins  of  the  cord  and  avoidance  of  injury  to  the  vas  deferens. 

2.  Use  of  the  cremaster  muscle  and  fascia  to  strengthen  the  closure. 

3.  Overlapping  of  the  various  structures  brought  into  apposition. 

4.  Reinforcement  of  the  lower  part  of  the  wound  when  necessary  by  a  flap  of  rectus 
fascia  or  by  rectus  transplantation. 


502  HERNIA. 


UMBILICAL  HERNIA. 


The  classical  method  of  operating  in  cases  of  umbilical  hernia  was  to  make 
a  vertical  incision  more  or  less  over  the  centre  of  the  swelling,  open  the  sac, 
free  the  contents,  reducing  intestine  and  excising  redundant  omentum.  Ran- 
sohoff  has  shown  that  much  time  is  lost  and  danger  to  viscera  incurred  by 
this  method  of  attack,  and  has  laid  down  the  principle  that  the  incision  should 
always  be  made  into  the  free  abdominal  cavity  at  the  neck  of  the  sac. 

Modified  as  above,  the  classical  operation  may  be  described  as  follows: 
Step  I. — Make  a  vertical  incision  from  a  point  well  above  the  hernia  to 
a  similar  point  below.     When  passing  over  the  hernia,  the  incision  should  be 
deflected  to  one  side  or  the  other  of  the  umbilicus  (Fig.   596). 

Step  2. — Through  the  above  incision  without  opening  the  sac  dissect  down 
to  and  freely  expose  the  aponeurotic  structures  at 
one  side  of  the  neck  of  the  hernia. 

Step  3. — Open  the  sac  at  its  neck;  reduce  any 
extruded  gut.  Ligate  and  divide  redundant  omentum 
and  reduce  the  omental  stump.  Place  a  gauze  pad 
against  the  opening  into  the  abdomen  and  excise  the 
hernial  sac,  the  remains  of  omentum  which  it  may 
contain,  and  such  redundant  skin  as  may  require 
Y^Q    .  g  removal.      This   excision  may  be  done  rapidly,  as 

all  danger  of  injury  to  gut,  etc.,  has  been  avoided 
by  its  early  isolation  and  reduction. 

Step  4. — Close  the  peritoneal  wound  by  a  row  of  catgut  sutures. 
Step  5. — By  sharp  and  blunt  dissection  open  the  rectus  sheath  on  both 
sides  of  the  wound  and  expose  the  edge  of  both  recti  muscles. 

Step  6. — Unite  the  posterior  layer  of  rectus  fascia  or  sheath  by  sutures. 
Suture  together  the  rectus  muscles.  Unite  the  anterior  layer  of  rectus  fascia. 
Close  the  skin- wound. 

The  above  is  a  good  operation  in  cases  of  small  hernia;  but,  as  the  Mayos 
have  shown,  when  the  hernia  is  large,  and,  as  is  usually  the  case,  the  patient 
is  fat,  there  is  a  wide  separation  between  the  recti  and  these  muscles  are  them- 
selves atrophied.  The  classical  operation  has  therefore  proved  inefficient, 
in  the  very  cases  where  success  is  most  to  be  desired.  The  Mayos'  operation 
has  become  the  recognized  procedure.  It  does  not  seek  to  obtain  muscular 
apposition  but  depends  for  success  on  the  formation  of  a  strong  aponeurotic 
barrier. 

The  Mayos'  Operation  (Figs.  597,  598,  599). — Step  i. — Make  transverse 
elliptical  incisions  around  the  umbilicus  and  the  hernia.  Deepen  these  to 
the  base  of  the  hernial  protrusion. 

Step  2. — For  an  inch  and  a  half  in  all  directions  from  the  neck  of  the. sac 
carefully  expose  the  aponeurotic  structures. 

Step  3. — Divide,  in  a  circular  manner,  the  fibrous  and  peritoneal  coverings 


UMBILICAL   HERNIA. 


503 


of  the  hernia  at  the  neck.  Expose  the  hernial  contents.  If  viscera  are  pres- 
ent, separate  the  adhesions  and  reduce.  Ligate  the  contained  omentum  and 
remove  it  with  the  entire  sac  of  the  hernia. 

Step  4. — Grasp  with  forceps  and  approximate  the  margins  of  the  ring. 
In  whatever  direction  overlapping  proves  easiest  lies  the  proper  direction 
for  closure. 

Step  5. — Incise  the  aponeurotic  and  peritoneal  structures  of  the  ring  for 
a  distance  of  one  inch  or  more  transversely  to  each  side.  Separate  the  perit- 
oneum from   the  under  surface  of    the  upper  of   the  two  flaps  thus  formed. 


Fig. 


Mavo.) 


Step  6. — Beginning  one  inch  or  more  above  the  margin  of  the  upper  flap, 
introduce  three  or  four  mattress  sutures,  the  loop  firmly  grasping  the  upper 
margin  of  the  lower  flap.  Make  sufficient  traction  on  these  sutures  to  permit 
of  closure  of  the  peritoneum  with  a  continuous  catgut  suture.  Tie  the  mattress 
sutures,  sliding  or  pulling  the  entire  lower  aponeurotic  flap  into  the  space 
between  the  peritoneum  and  aponeurosis  above. 

Step  7. — With  catgut,  suture  the  lower  edge  of  the  upper  aponeurotic 
flap  to  the  aponeurosis  below.     Close  the  superficial  wound. 


504 


HERNIA. 


Kelly's  modification  of  the  Mayos'  operation.     ("Annals  of  Surg.,"  May, 
1910). 

Step  I. — Make  a  curved  transverse  incision  across  the  hernia  from  a  point 


Fig.  598. — [Mayo.) 


Fig.  599.; — (Mayo.) 

slightly  external  to  the  right  rectus  to  a  point  slightly  external  to  the  left  rec- 
tus muscle.  The  concavity  of  the  curve  is  directed  upwards.  Expose  the 
fascia  over  both  recti. 


UMBILICAL  HERNIA. 


:)^D 


Step  2. — Divide  the  fascia  over  both  recti  and  separate  it,  from  the  muscles, 
upwards  and  downwards  for  a  distance  of  2  or  3  cm.  (3/4-1  1/8  inches)  so  as 
to  form  fascial  flaps.     (Fig.  600). 

Step  T^. — Isolate  and  open  the  hernial  sac.  Treat  its  contents  in  the  usual 
fashion. 

Step  4. — Close  the  peritoneal  wound  with  catgut  sutures. 

Step  5. — "Haul  up  and  sew  the  free  margin  of  the  lower  under  the  upper 
tlap  from  side  to  side  vidth  four  to  six  interrupted  silk  sutures,  using,  if  needs 
be,  catgut  between  them.  If  the  transrectal  incision  is  angled  a  little  upwards 
and  the  overlapping  of  the  recti  is  well  done,  there  may  be  little  tension;  there 
is  always  a  greatly  diminished  tension  in  the  overlapping  at  the  ring  itself." 


Fig.  600. 


Suture  the  ffee  overhanging  margin  of  the  upper  flap  to  the  fibrous  tissues 
by  a  continuous  catgut  suture. 

Step  6. — Close  the  skin  wound. 

When  a  large  defect  in  the  abdominal  wall  cannot  be  closed  in  the  above 
manner  or  in  some  modification  thereof,  closure  has  been  effected  by  means 
of  a  perforated  celluloid  plate  (McCosh)  or  of  a  silver  wire  meshwork  (Phelps, 
Willy  Meyer,  Bartlett).  Meyer  is  very  urgent  in  the  praise  of  this  method  of 
closure.  The  meshwork  or  fence  of  silver  wire  seems  to  be  well  borne  by  the 
tissues  and  to  form  the  nucleus  of  a  strong  mass  of  connective  tissue. 

The  author  has  used  Bartlett's  wire  mesh  with  great  satisfaction  in  a 
case  of  hernia  resulting  from  loss  of  much  of  the  upper  end  of  the  right  rectus 
abdominis  muscle.  Kirschner's  plan  (p.  501)  of  the  "free"  transplantation 
of  a  flap  of  fascia  lata  may  possibly  supplant  the  use  of  foreign  materials. 

Ventral  hernia?  of  all  varieties  are  to  be  treated  on  the  same  principles 
as   are   advocated   for   umbilical   herniae.     Undoubtedly    the   best   treatment 


5o6 


HERNIA. 


for  post-operative  ventral  herniae  is,  to  use  an  Irishism,  not  to  have  them. 
For  this  purpose  nothing  is  better  than  attention  to  cleanhness,  careful  closure 
of  the  parietes  in  their  anatomic  layers,  and  absolute  avoidance  of  strain  un- 
til the  embryonic  tissues  necessary  for  the  repair  of  abdominal  v^^ounds  have 
had  time  to  become  mature. 

Rutherford  Morison's  Operation. — (i)  Make  long  transverse  incisions 
including  the  hernia  in  an  ellipse.  (2)  Expose  the  rectus  sheath  above, 
below  and  on  each  side  of  the  hernia.  (3)  Open  the  sac  and  the  abdomen 
through  the  linea  alba  below  the  hernia.  (4)  Reduce  the  hernial  contents, 
never  cutting  away  omentum  unless  absolutely  necessary.  Cut  away  sac. 
(5)     With  fingers  in  the  abdomen  introduce  thick  catgut  mattress  sutures 


Fig.  601. — Wullstein's  Oper.'^tion  for  Ventral  Hernia. 


through  the  aponeurosis  and  rectus  muscle  on  either  side  but  do  not  tighten 
them.  Separate  and  hold  up  the  mattress  sutures  so  as  to  expose  the  perito- 
neal wound.  Suture  the  peritoneal  wound.  Infold  the  aponeurosis  by  tighten- 
ing and  tying  the  mattress  sutures,  making  a  keel  towards  the  abdominal 
cavity  and  bringing  broad  surfaces  of  aponeurosis  into  apposition.  Draw 
surfaces  of  aponeurosis  still  more  together  by  thick  interrupted  catgut  sutures 
above,  below  and  between  the  mattress  sutures.  (6)  Drain  cavity  with  a 
tube  introduced  by  small  incision  through  the  upper  flap.  (The  skin  of  the 
lower  flap  is  often  moist  and  infected.)  (7)  Apply  dressings  and  support 
the  abdomen  with  adhesive  straps. 

Wullstein's   operation  for  ventral  hernia  is  sufficiently  described  by  Fig. 
601.     (Zentralblatt  fiir  Chir.,  Sept.  22,  1906,  p.  153.) 


CHAPTER  XLIII. 
RETRO-PERITONEAL  AND  DIAPHRAGMATIC  HERNIA. 

RETRO-PERITONEAL  OR  INTERNAL  HERNIA. 

Normally  the  peritoneal  cavity  is  provided  with  a  number  of  apertures 
or  fossae  which,  under  ordinary  circumstances,  are  entirely  harmless,  but 
which  may  become  dangerous  owing  to  various  anomalies  of  development 
and  to  adverse  circumstances.  The  following  are  the  most  important  of 
these   structures: 

1.  The  foramen  of  Winslow.  In  a  few  cases  small  intestine  has  entered 
the  lesser  peritoneal  sac  through  this  opening.  The  condition,  if  found  dur- 
ing life,  demands  that  the  herniated  intestine  be  reduced  into  its  proper  loca- 
tion and  that  the  foramen  be  lessened  in  size  or  obliterated.  Probably  the 
trauma  due  to  the  hernia  and  its  reduction  will  produce  enough  plastic  per- 
itonitis to  efifect  obliteration;  a  gauze  or  cigarette  pack  introduced  into  the 
foramen  would  act  similarly,  or  one  or  two  catgut  sutures  may  be  judiciously 
introduced. 

2.  Recessus  duodenojejunalis.  At  the  point  where  the  duodenum  passes 
into  the  jejunum  a  fold  of  peritoneum,  containing  the  inferior  mesenteric 
vein,  forms  a  semilunar  opening  to  the  left  of  the  origin  of  the  jejunum  (Fig. 
602).  Usually  this  opening  or  recess  is  shallow  and  not  wider  than  a  man's 
thumb.  Jonnesco  and  others  have  described  several  varieties  of  recess  in 
this  situation,  but  for  our  purposes  the  recognition  of  its  existence  and  of  its 
proneness  to  vary,  suffices.  Intestine  may  bore  its  way  into  the  recess  de- 
scribed, enlarging  the  opening  and  forming  a  retroperitoneal  hernia  (Treitz's 
hernia).  The  pouch  formed  by  the  herniated  gut  may  stretch  to  the  left 
under  the  descending  colon  and  downwards  to  the  pelvis.  Upwards  the  hernia 
may  pass  under  the  root  of  the  transverse  mesocolon  to  a  position  behind 
the  stomach  and  spleen.  Strangulation  is  rare.  It  is  commonly  supposed 
that  small  intestine  alone  is  involved,  but  Freeman  ("Transactions  American 
Surg.  Assoc,"  1903)  describes  a  case  in  which  the  sac  contained  the  entire 
small  intestine,  the  caecum  and  a  portion  of  the  colon,  which  was  strangulated. 
A.  Narath  ("Archiv  f.  klin.  Chir.,"  Ixxi,  911)  reports  a  case  in  which  prior 
to  operation  the  diagnosis  was  pyloric  or  gall-bladder  tumor.  When  the 
abdomen  was  opened  above  the  umbilicus,  the  small  intestines  presented  in  front 
of  the  great  omentum,  the  transverse  colon,  and  the  stomach.  When  the 
small  intestine  was  pulled  out  of  the  belly  cavity  for  inspection,  the  caecum 
and  vermiform  appendix  followed,  appearing  above  the  lesser  curvature  of 
the  stomach.     The  case  was  one  of  hernia  through  the  recessus  duodenojejun- 


5o8 


RETRO-PERITONEAL  AND    DIAPHRAGM/XTIC   HERNIA. 


alls;  the  gut  passed  up  behind  the  stomach  and  then  forwards  through  the 
gastro-hepatic  omentum.  Reduction  was  easy,  and  the  duodenojejunal 
opening  was  closed  by  a  few  stitches  of  catgut.* 

3.  Pericsecal  fossae.  Three  fossae  exist  in  the  neighborhood  of  the  ileo- 
caecal  junction  (Fig.  603):  (a)  Ileo-colic  fossa,  which  lies  above  the  ileum 
and  below  the  ileo-colic  fold  containing  the  colic  branch  of  the  ileo-colic  artery. 
(b)  Ileo-ca^cal  fossa.  The  orifice  of  this  fossa  is  situated  below  the  ileum, 
where    it  joins  the  cjecum.     The  fossa  may  be  large  and  extend  upwards 


Pica  duodeno- 
mesocolica 


Duodenum. -- 


Inferior  mesenteric  vein  Left  colic  artery 

Fig.  602. — (Ziickerkandl.) 

posterior  to  ascending  colon  as  far  as  the  right  kidney,  (c)  Subcaecal  fossa 
This  fossa  lies  beneath  the  ca?cum  and  external  to  the  meso-appendix  and 
meso-caecum.  Any  one  of  the  pericecal  fossae  may  be  the  site  of  an  internal 
hernia,  especially  if  its  normal  relations  have  been  altered  by  attacks  of  ap- 
pendicitis. The  fossae  are  also  of  surgical  importance,  as  they  may  be  filled 
with  the  products  of  inflammation  in  appendicitis,  and  into  one  of  them  the 
appendix  itself  may  be  herniated. 

4.  The  intersigmoid  fossa  (Fig.  604).  On  the  lower  or  left  surface  of 
the  meso-sigmoid  a  fossa  may  exist  which  is  variable  in  size.  A  few  cases 
of  hernia  have  been  described  in  which  this  fossa  formed  the  sac. 

Many  operations  have  been  undertaken  for  the  treatment  of  obscure 
intestinal  obstruction,  chronic  or  acute,  and  in  many  of  these,  symptomatic. 

*  For  extended  information  on  this  subject  the  reader  is  referred  to  Freeman's  paper 
already  mentioned,  to  Moynihan's  work,  "Retroperitoneal  Hernia,"  London,  1906,  to  Jon- 
nesco's  "Hernies  internes  retro-peritoneales,"  Paris,  1890.  Vautrin,  "Les  Hernies  Paraduo- 
denales,"  Rev.  de  Chir.,  Jan.,  1907. 


RETRO-PERITONEAL   HERNLA. 


509 


recovery  has  ensued,  although  no  cause  was  discovered  during  the  operation. 
Undoubtedly  in  many  of  these  cases  an  internal  hernia  has  been  overlooked 
or  has  been  reduced,  unknown  to  the  operator,  by  the  manipulations  necessary 
in  exploration. 


Superior  ileo-caeca  fossa 
P. 


UfM^    .-^^  / 


Infenoi  Ueo  caeca  fossa 


Fig.   603. — {Ziickerkandl.) 
Sigmoid 


Intersigmoid    fossa 


^fc     Descending  colon 


^  -.<f "' 


6U 


Ureter 
¥\(i.  604. — {Ziickerkandl.) 


This  short  chapter  has  been  written  to  direct  the  attention  of  the  junior 
surgeon  to  the  probable  sites  of  internal  hernia.\  The  author  believes  that 
internal  hernice  are  verv  much  more  common  than  statistics  would  indicate. 


5IO  REMARKS    ON    LARGE   HERNIA. 

Occasionally  hernias  become  so  large  and  contain  so  many  organs  that 
these  organs  may  be  said  to  have  lost  their  right  of  domicile  in  the  abdomen, 
and  hence  reduction,  whether  operative  or  non-operative,  becomes  impossible 
or  unjustifiable.  In  other  cases  adhesions  uniting  the  hernial  contents  to 
each  other  and  to  the  sac  constitute  a  condition  which,  either  alone  or  in  com- 
bination with  a  poor  state  of  the  general  health,  contraindicate  any  attempt 
at  reduction.  In  such  cases  when  strangulation  or  obstruction  becomes 
evident,   what  means  have  we  to  overcome  their  disastrous  results? 

If  the  strangulation  is  due  to  constriction  at  the  hernial  orifice,  common 
sense  tells  us  to  divide  the  constriction  by  free,  open  incision,  and,  contrary 
to  the  practice  in  "radical  cure,"  to  endeavor  to  retain  the  increased  patency 
of  the  opening  between  the  abdominal  cavity  and  the  hernial  sac.  In  other 
words,  our  aim  ought  to  be  to  make  the  abdominal  cavity  and  hernial  sac 
as  nearly  as  possible  one. 

Usually  in  large  herniae  nature  has  so  dilated  the  abdominal  orifice  that 
strangulation  at  this  point  is  rare.  It  is  more  common  to  find  that  adhes'ons, 
bands,  diverticula,  etc.,  in  the  hernial  sac  itself  are  the  cause  of  strangulation. 
As  Madelung  ("Archiv  f.  klin.  Chir.,"  Ixxiv,  60)  points  out,  gangrene  may 
be  far  advanced  in  hernias  of  this  class,  and  symptoms  be  almost  absent; 
thus  during  operation  one  may  be  compelled  to  excise  a  considerable  amount 
of  diseased  gut,  joining  the  afferent  and  efferent  sections  by  anastomosis  or 
enterorrhaphy,  or  may  establish  a  faecal  fistula.  Some  surgeons  have,  on 
general  principles,  excised  a  mass  of  herniated  gut,  so  that  reduction  of  the 
remainder  became  possible  and  a  radical  cure  could  be  effected. 

In  very  large  herniEe  there  is  always  some  obstruction  to  the  onward  passage 
of  fceces;  this  obstruction  varies  from  time  to  time.  Mild  exacerbations  are 
usually  successfully  treated  by  purgation,  enemata,  rest  in  bed,  massage, 
etc.,  but  occasionally  operative  interference  becomes  necessary.  Madelung 
writes:  "In  many  cases,  especially  the  old  and  feeble,  when  coprostasis 
has  continued  for  a  long  time,  it  is  very  proper  to  establish  a  fistula  in  the  affer- 
ent gut.  Under  local  anaesthesia  this  is  absolutely  without  danger  even  in 
the  most  debilitated.  The  fistula  should  be  small,  about  the  size  of  a  medium- 
sized  Paquelin  cautery  point.  It  should  drain  only  part  of  the  intestinal 
contents,  acting  as  a  kind  of  safety-valve."  When  the  patient  is  strong  enough 
to  withstand  a  more  severe  operation,  intra-abdominal  anastomosis  between 
the  afferent  and  efferent  loops  of  gut  serves  to  segregate  or  exclude  the  affected 
viscera  (see  "Intestinal  Exclusion").  It  is,  of  course,  impossible  to  formulate 
precise  rules  for  the  operative  treatment  of  irreducible  hernias,  but  it  is  hoped 
the  above  brief  remarks  may  aid  the  inexperienced  practitioner  in  an 
emergency. 

DIAPHRAGMATIC  HERNIA. 

The  diaphragm  is  the  site  of  several  actual  or  potential  openings,  the  prin- 
cipal one  being  that  between  the  costal  and  sternal  origins  of  the  muscle,  and 


DIAPHRAGMATIC   HERNIA.  $11 

known  as  the  foramen  of  Morgagni.  Hernia  through  Morgagni's  foramen 
is  known  as  parasternal  hernia,  and  is  provided  with  a  double  sac,  of  pleura 
and  peritoneum.  For  our  purpose  it  is  useless  to  differentiate  between  the 
so-called  true  hernia  and  the  false,  where,  owing  to  injury,  there  is  a  prolapse 
of  abdominal  organs  into  the  thorax.  Very  few  diaphragmatic  hernioe  have 
been  diagnosed;  most  have  been  discovered  during  operation  or  autopsy. 
The  commonest  cause  of  diaphragmatic  hernia  is  trauma,  usually  from  knife 
or  bullet,  and  the  proper  treatment  is  immediate  operation.  In  Lacher's 
statistics  of  36  traumatic  cases  not  submitted  to  operation,  15  died  from  hernia 
after  periods  varying  from  a  few  days  to  a  month,  and  10  died  in  from  five  to 
twenty  years  from  the  same  cause.  A  wound  of  the  diaphragm  when  left 
to  itself  may  heal,  but  the  scar  remains  weak  and  hernia  is  the  common 
result.  This  being  true,  the  best  treatment  for  traumatic  diaphragmatic 
hernia  is  prophylactic.  The  wound  of  entrance  is  almost  always  in  the 
thorax.  Enlarge  the  wound,  excise  two  inches  or  more  of  one  or  two 
ribs,  as  may  be  required  to  give  room.  Note  if  the  pleura  is  or  is  not  injured. 
In  a  case  operated  on  by  the  writer  the  pleura  was  uninjured,  though  the  dia- 
phragm was  penetrated  and  omentum  was  present  in  the  thorax.  Expose 
and  examine  the  diaphragm.  If  the  diaphragm  has  been  penetrated  and 
omentum  or  hollow  viscera  present,  examine  and  repair  any  injury  they  may 
have  sustained.  Open  the  abdomen  either  by  a  median  or  lateral  incision, 
or,  as  Neugebauer  ("Archiv  f.  klin.  Chir.,"  Ixxiii,  1014)  did,  by  a  cut  divid- 
ing the  costal  arch.  It  is  usually  easier  to  reduce  the  prolapsed  organs 
after  the  abdomen  has  been  opened,  and  it  is  necessary  to  explore  the  abdo- 
men in  search  for  further  injuries.  If  no  abdominal  contents  are  prolapsed 
through  the  diaphragmatic  wound,  open  the  abdomen  and  search  for  any 
injuries  to  its  contents.  If  the  liver  is  injured,  treat  such  injuries  secundem 
artem.  Close  the  wound  in  the  diaphragm  with  sutures  introduced  by  the 
transthoracic  route.  Close  the  wound  in  the  abdomen  and  thorax  with  or 
without  drainage.  In  52  cases  of  diaphragmatic  suture  (where  there  was  no 
strangulated  hernia)  the  mortality  was  9.6  per  cent,  when  the  transthoracic 
route  was  adopted;  in  10  similar  cases  when  the  abdominal  route  was  used 
the  mortality  was  50  per  cent.  Of  the  cases  of  strangulated  diaphragmatic 
hernia  collected  by  Neugebauer,  all  those  operated  on  through  the  abdominal 
route  died;  one  out  of  two  operated  on  through  the  thorax  lived.  The  only  two 
cases  of  non-strangulated  diaphragmatic  hernia  submitted  to  radical  cure 
(Llobet's  and  Cranwell's)  lived  after  a  transthoracic  operation.  When  operation 
is  performed  for  obscure  abdominal  lesions,  one  ought  to  remember  and  look 
for  diaphragmatic  hernia,  and  if  such  is  found,  one  ought  not  to  waste  time 
endeavoring  to  reduce  it  from  the  abdominal  side,  but  proceed  at  once  to  open 
the  chest.  Suture  of  the  diaphragm  from  below  is  extremely  difficult  and 
necessitates  very  much  disturbance  in  a  region  rich  in  important  nerves. 
Prolapsed  masses  which  it  is  impossible  to  reduce  from  the  abdomen  alone 
are  easily  reduced  or  slip  back  of  themselves  as  soon  as  the  chest  is  well  opened. 


512 


RETRO-PERITONEAL  ANDD  lAPHRAGMATIC  HERNM. 


That  the  clangers  from  pneumothorax  are  not  so  great  as  is  usually  imagined 
is  shown  by  the  small  mortality  (9.6  per  cent.)  after  recent  wounds  of  the 
thorax.  Furthermore,  if  the  hernia  is  reduced  through  the  abdominal  route, 
pneumothorax  must  occur  immediately  the  hernia  ceases  to  plug  the  diaphrag- 
matic wound,  while  the  establishiuent  of  pneumothorax  prior  to  reduction 
aids  marvelously  in  obtaining  this  reduction. 

Cranwell    ("Rev.   de   Chir.,"    Jan.,    1908)    recognized   the  presence  of   a 
diaphragmatic  hernia  before  he  operated.     His  patient   was  placed  on  his 


0"' 


Fig.  605. — Cran well's  Oper-^tign  for  Diaphragmatic  Hernia. 
P.  Pleura.     D.   Diaphragm.     O.  Omentum.     C.  Colon. 

side  in  the  reversed  Trendelenburg  posture.  The  lower  and  lateral  part 
of  the  thorax  was  opened  by  a  flap  having  its  base  above,  consisting  of  the 
whole  thickness  of  the  chest-wall  and  containing  about  5  inches  of  the  ninth 
and  eighth  ribs  (Fig.  605).  In  spite  of  numerous  adhesions  the  prolapsed 
omentum  and  colon  were  reduced,  the  openings  in  the  diaphragm  and  in 
the  pleura  were  sutured  arid  the  external  wound  closed.  The  patient  recovered. 
The  hernia   was   due   to   an   old   stab-wound  which  had  healed. 


PART  IV.— THE  GENITO-URINARY  SYSTEM. 


CHAPTER  XLIV. 
OPERATIONS  UPON  THE  KIDNEY. 

METHODS  OF  EXPOSING  THE  KIDNEY. 

I.  Posterior  or  Lumbar  Route. — There  are  two  positions  in  which  the 
patient  may  be  placed: 

(a)  The  classical  or  lateral  posture.  Place  the  patient  upon  his  sound 
side  with  his  back  near  the  edge  of  the  operating  table  and  his  thighs  and 
knees  well  flexed.  To  increase  the  space  between  the  thorax  and  ilium, 
place  a  roll-shaped,  firm  pillow  under  the  loin  of  the  sound  side.  The  surgeon 
stands  at  the  patient's  back. 

(6)  The  prone  position.  This  position  is  the  best  for  most  purposes. 
Lay  the  patient  prone  upon  the  table.     Place  a  large  pillow  (Edebohls'  air- 


FiG.  606. — (Edebolils,  '^Annals  of  Surg.") 

cushion,  12  inches  long  by  8  inches  in  diameter,  is  excellent)  beneath  his  ab- 
domen with  its  long  axis  at  right  angles  to  the  long  axis  of  the  body.  This 
lifts  the  kidneys  into  the  field  of  operation  and  gives  the  widest  possible  costo- 
iliac  space.  The  operating  table  referred  to  as  suitable  in  operations  on  the 
bile  ducts  is  of  value  here  to  replace  sand-bags  and  cushions  (see  p.  454). 

(A)   Vertical  Incision   (Simon). — Recognize   the  last  rib   and  the  erector 
spinas  muscle.     Make  a  vertical  incision  from  the  last  rib  downwards,  parallel 

33  513 


514 


OPERATIONS    UPON    THE    KIDNEY. 


and  close  to  the  outer  edge  of  the  erector  spime  muscle.  This  penetrates  the 
skin  and  subcutaneous  tissue  and  extends  nearly  to  the  crest  of  the  ilium.  The 
latissimus  dorsi  is  now  seen.  Separate  but  do  not  cut  its  muscular  fibres 
(Figs.  606  and  607).  The  erector  spina)  muscle  presents.  Retract  it  in- 
ward, but  do  not  open  its  sheath.  Expose  and  open  the  sheath  of  the  quad- 
ratus  lumborum  along  its  outer  margin  for  the  full  length  of  the  wound.  As 
the  pleura  occasionally  extends  below  the  last  rib,  it  is  wise  to  avoid  the  neigh- 
borhood of  this  rib  while  making  deep  dissection.  By  keeping  one  inch 
below  the  rib,  all  danger  to  the  pleura  is  avoided  and  at  a  little  later  period 
„^  in   the  operation  the  wound  can  be 

safely  enlarged  upwards  under  guid- 
ance of  the  finger.  As  soon  as  the 
fascia  lumborum  or  transversalis  fascia, 
lying  in  front  of  the  quadratus  lum- 
borum, is  divided,  perirenal  fat  bulges 
into  the  wound.  Remember  that  the 
last  thoracic,  iliohypogastric,  and  ilio- 
inguinal nerves  lie  between  the  quad- 
ratus muscle  and  the  kidney.  These 
nerves,  when  met  with,  should  be  care- 
fully pulled  aside,  or  if  it  is  necessary  to 
divide  one  of  them,  the  severed  ends 
ought  to  be  caught  up  in  a  suture,  so 
that  when  the  operation  is  completed 
and  the  wound  is  being  closed,  they 
may  be  once  more  united  (Edebohls). 
Failure  to  attend  to  this  point  may 
lead  to  an  annoying  and  persistent  pain  in  the  thigh  after  operation.  When 
the  perirenal  fat  is  exposed,   tear  through  it  and  expose  the  kidney. 

If  the  above  incision  does  not  give  sufficient  room,  make  a  small  trans- 
verse incision  through  the  outer  fibres  of  the  quadratus  muscle  near  the  ilium; 
this  simple  proceeding  is  of  great  aid.  To  gain  more  room,  some  surgeons 
have  recommended  excision  of  the  last  rib,  but  this  has  not  proved  of  much 
value.  A  better  suggestion  has  been  made,  namely,  to  fracture  the  last  rib 
and  turn  it  upwards.  It  is  easy  to  deliver  the  kidney  on  to  the  back  through 
this  incision. 

(B)  Oblique  Incision  (Bergmann). — P>om  the  outer  edge  of  the  erector 
spinas,  at  the  level  of  the  twelfth  rib,  make  an  incision  downwards  and  outwards 
towards  the  junction  of  the  outer  and  middle  thirds  of  Poupart's  ligament. 
The  length  of  the  incision  varies  with  the  work  to  be  done  and  the  size  of  the 
operator's  hand.  It  must  be  large  enough  to  give  free  access  to  the  kidney. 
A  cut  four  inches  in  length  is  generally  sufficient  for  exploratory  purposes 
and  may  readily  be  enlarged.  The  lower  border  of  the  latissimus  dorsi  pre- 
sents and  must  be  divided.     Layer  by  layer  cut  through  the  external  oblique, 


Fig.  607.- — {Esinarch  and  Kowalzig.) 
I.  External  oblique.  2.  Internal  oblique. 
3.  Transversalis.  4.  Transversalis  fascia. 
5,  6,  7.  Lumbo-dorsal  fascia.  8.  Sacro- 
spinalis.  9.  Quadratus  lumborum.  10.  Psoas. 
II.  Colon.  12.  Pancreas.  13.  Kidney.  14. 
Spleen. 


EXPOSURE    OF    KIDNEY.  515 

the  internal  oblique,  the  transversalis  muscle.  Under  the  last-named  muscle 
lies  the  transversalis  fascia.  Make  a  small  opening  in  the  fascia  and,  guided 
by  the  finger  passed  through  the  opening,  divide  it  for  the  whole  length  of 
the  wound.  The  quadratus  lumborum  lies  at  the  upper  and  inner  part  of 
the  wound  and  is  either  retracted  towards  the  spine  or  divided,  as  may  be 
convenient.  After  division  of  the  transversalis  fascia  the  perirenal  fat  pre- 
sents and  is  torn  through  until  the  kidney  is  reached.  During  the  deeper 
dissection  care  must  be  taken  not  to  injure  the  pleura  should  it  descend  below 
the   last    rib. 

(C)  Triangular  Incision  (Konig). — From  the  outer  edge  of  the  erector 
spinae,  at  the  level  of  the  twelfth  rib,  cut  downwards  parallel  and  close  to  the 
erector  muscle  until  the  iliac  crest  is  reached.  From  the  lower  end  of  the 
wound  make  a  curved  incision  directed  towards  the  navel  and  reaching  to  the 
outer  margin  of  the  rectus  abdominalis.  The  division  of  the  deeper  structures 
is  carried  out  in  the  manner  already  described.  Any  parietal  peritoneum 
which  may  be  exposed  is  pushed  aside.  Very  free  access  to  the  kidney  or 
to  tumors  of  that  organ  is  attained. 

(D)  ZuckerkandVs  Incision. — From  the  outer  edge  of  the  erector  spinae, 
at  the  level  of  the  twelfth  rib,  cut  downwards  to  the  middle  of  the  iliac  crest; 
from  the  latter  point  cut  forwards  to  near  the  anterior  superior  spine  of  the 
ilium.     The  deep  dissection  is  done  as  already  described. 

(E)  Trap-door  Incision  (Bardenheuer). — From  the  upper  and  lower 
extremities  of  the  vertical  incision  (A)  make  horizontal  cuts  parallel  to  the 
lower  edge  of  the  thorax  and  to  the  iliac  crest  respectively.  If  these  cuts  run 
forwards,  a  trap-door  is  formed  which  can  be  reflected  or  retracted  anteriorly; 
if  they  run  backwards  (/.  e.,  towards  the  spine),  one  which  can  be  turned  back- 
wards is  the  result.  In  some  cases  it  may  be  desirable  to  form  both  an  ante- 
rior and  a  posterior  trap-door  flap. 

Should  the  peritoneum  be  opened  during  the  operation,  it  ought  to  be 
closed  at  once  by  suitable  sutures. 

(F)  C.  T.  Parkes''  Incision. — Make  a  curved  incision  from  a  point  two 
inches  above  the  anterior  superior  spine  to  the  tip  of  the  last  rib.  Expose 
the  fascia  transversalis.  With  the  finger  dissect  well  behind  the  tumor  of 
the  kidney.  Having  separated  all  the  parts,  make  a  straight  incision  back- 
wards from  the  first  cut  and  half-way  between  the  crest  of  the  ilium  and  the 
last  rib.     An  excellent  exposure  is  obtained  of  the  kidney,  vessels,  and  ureter. 

II.  Anterior  or  Abdominal  Route. — If  the  kidney  to  be  exposed  is 
very  large,  an  incision  may  be  made  over  the  tumor  at  any  place  which  may 
seem  suitable  or  advisable.  Such  an  incision  will  be  either  vertical  or  oblique 
(running  from  above  downwards  and  inwards).  Langenbuch's  incision  will 
generally  be  found  to  be  the  best,  as  it  gives  free  access  to  the  renal  vessels 
and  avoids  unnecessary  exposure  of  the  intestines.  Kiister  makes  it  a  rule  to 
operate  by  the  transperitoneal  route  in  cases  of  neoplasm  when  diiEculties  and 
adhesions  are  present;  if  the  tumor  is  very  mobile  he  chooses  the  lumbar  route. 


5l6  OPERATIONS    UPON   THE    KIDNEY. 

Langenbuch's  Method. — Form  a  point  immediately  below  the  ribs  and  about 
three  inches  from  the  middle  line  cut  downwards  for  a  distance  of  four  inches. 
Find  the  outer  edge  of  the  rectus  muscle  (linea  semilunaris).  Cut  down  to 
the  peritoneum,  following  the  semilunar  line.  Open  the  peritoneum  carefully 
in  the  same  manner  as  a  sac  is  opened  during  a  herniotomy.  Introduce  the 
hand  and  examine  the  opposite  kidney  and  ureter.  This  is  a  most  important 
precaution,  and  must  always  be  observed.  The  opportunity  afforded  to  ex- 
amine the  opposite  kidney  constitutes  one  of  the  advantages  of  the  abdominal 
route  over  the  lumbar.  Von  Eiselsberg  convinced  himself  by  touch  (of  the 
hand  in  the  abdomen)  that  the  second  kidney  was  present,  yet  after  nephrectomy 
the  patient  died  from  uremia.  Autopsy  showed  absence  of  the  other  kidney, 
the  surgeon  having  taken  an  induration  of  the  pancreas  to  be  a  kidney.  The 
opposite  kidney  and  ureter  being  found  healthy,  the  intestines  are  covered 
with  a  large  flat  gauze  pad  and  kept  out  of  the  way.  The  outer  surface 
of  the  mesocolon  is  exposed  and  a  small  hole  made  in  its  outer  layer.  This 
hole  is  enlarged  by  tearing.  The  vessels  which  pass  through  the  mesocolon 
lie  close  to  its  inner  layer,  and  thus  injury  to  them  is  avoided.  Through 
the  opening  in  the  mesocolon  the  kidney  is  easily  and  completely  exposed. 

Rutherford  M orison's  Incision. — Open  the  abdomen  through  the  rectus 
muscle.  Make  a  transverse  incision  from  this  back  to  the  centre  of  the  ilio- 
costal space.  Morison  writes:  "This  allows  pus  to  escape  behind  and  away 
from  the  peritoneum,  perfect  drainage  after,  and  good  access  to  vessels 
and  ureter  during  operation."  It  also  permits  exploration  of  the  opposite 
kidney  at  the  beginning  of  the  operation. 

Nephropexy  or  Nephrorrhaphy. — Method  I. — Expose  the  kidney  by 
incision  A  or  B.  Excise  most  of  the  fatty  capsule  lying  posterior  to  the  kidney. 
An  assistant  with  his  fist  pressing  on  the  belly  pushes  the  kidney  up  into  the 
loin.  Pass  a  curved  needle,  armed  with  a  thick  suture,  through  the  muscles 
and  fascia  of  the  back  which  form  the  outer  edge  of  the  wound,  through  the 
remnants  of  the  fatty  capsule  and  into  the  kidney  parenchyma  near  the  outer 
convex  border  of  the  kidney.  The  needle  penetrates  the  kidney  to  a  depth 
of  about  one-half  inch  and  emerges  at  a  point  about  three-quarters  of  an 
inch  internal  to  its  point  of  entrance.  After  emerging  from  the  kidney  the 
needle  passes  through  the  remnants  of  the  fatty  capsule  and  the  muscles 
and  fascia  of  the  back  which  form  the  inner  edge  of  the  wound.  Three 
such  sutures  are  put  in  place,  one  at  the  upper  end  of  the  kidney,  one  at  the 
lower,  and  one  in  the  middle;  but  none  of  them  are  tied.  The  deep  parts 
of  the  wound  in  the  back  are  now  approximated  by  buried  sutures.  When 
this  is  done,  the  three  sutures  which  pass  through  the  kidney  are  carefully 
tied.  No  pulling  upon  these  important  sutures  is  allowable,  otherwise  they 
would  cut  their  way  out  of  the  friable  kidney.  This  is  the  reason  for  closing 
the  deep  parts  of  the  lumbar  wound  {i.  e.,  the  parts  through  which  the  kidney 
sutures  pass)  before  the  kidney  sutures  themselves  are  tied.  The  superficial 
wound  is  closed.     Some  surgeons,   notably  Newman,   pass  a  drainage-tube 


NEPHROPEXY. 


517 


through  the  wound  to  the  kidney  so  as  to  produce  a  local  irritation  and  thus 
aid  in  the  formation  of  adhesions.  Suture  materials:  Mildly  chromicized 
catgut,  kangaroo  tendon,  silk  or  silkworm-gut. 

Method  II. — Is  the  same  as  Method  I,  except  in  one  particular:  After 
the  kidney  is  exposed  a  longitudinal  incision  is  made  through  the  fibrous  cap- 
sule, which  when  turned  outwards  and  inwards  like  the  lapels  of  a  coat,  forms 
an  outer  and  an  inner  flap.  The  parenchyma  of  the  kidney  is  thus  left  ex- 
posed for  a  width  of  about  three-quarters  of  an  inch  throughout  almost  the 
whole  length  of  the  posterior  surface  of  the  organ.  The  sutures  are  intro- 
duced as  before,  except  that  when  entering  and  leaving  the  kidney  they  pass 
through  the  folded  flaps  of  fibrous  capsule. 

The  advantages  claimed  for  this  method  are  {a)  that  better  union  takes 
place  between  the  kidney  and  the  muscles  and  fascia  at  the  back;  {h)  that 
the  threads  passing  through  the  folded  back  flaps  of  fibrous  capsule  are  less 
liable  to  cut  their  way  out  The  objections  urged  against  the  method  (especi- 
ally by  Albarran)  are  (a)  that  decortication  is  unnecessary;  {b)  that  sclerotic 
changes  are  more  liable  to  occur  and  injure  the  kidney. 

Method  III. — The  kidney  is  exposed  by  incision  B.  At  a  point  opposite 
the  lower  extremity  of  the  kidney  (when  it  is  pushed  up  into  its  normal  position) 
a  pocket  is  formed  by  separating  the  transver- 
salis  fascia  from  the  more  superficial  structures. 
Into  this  pocket  the  lower  end  of  the  kidney  is 
snugly  tucked.  One  or  two  sutures  unite  the 
kidney  to  the  surrounding  muscles  and  fascia 
and  the  wound  is  closed.  Pean  is  a  supporter 
of  the  above  operation. 

Method  IV  (Israel's). — Expose  kidney  by 
incision  A.  Recognize  the  last  rib.  Split  the 
fibrous  capsule  of  the  kidney  so  as  to  lay  bare  a 
narrow  strip  of  cortex  reaching  nearly  the 
whole  length  of  the  organ.  Through  the  upper 
part  of  the  posterior  surface  of  the  kidney  pass 
a  double  suture  of  thick  catgut  (Fig.  608,  A  A^, 
a  a^).  Cut  the  loop  of  the  suture  so  as  to 
leave  four  ends  of  suture  on  which  needles  are 
to  be  threaded.      Make  a  knot  on  the  double 

thread  of  catgut  where  it  enters  and  where  it  leaves  the  kidney  (z-z).  One 
of  the  threads  emerging  from  the  outermost  part  of  the  kidney,  having  been 
armed  with  a  needle,  is  passed,  first,  through  the  fatty  capsule  of  the  kidney, 
and  then  between  the  periosteum  and  the  posterior  surface  of  the  twelfth 
rib  (Fig.  608,  A  A^).  The  other  end  of  thread  emerging  from  the  kidney 
at  the  same  point  is  passed  subperiosteally  in  front  of  the  twelfth  rib  in  such 
a  manner  that  the  two  ends  surround  the  rib  under  its  periosteum.  The 
two  threads  are  knotted  together.     The  two  ends  of  the  catgut  threads  which 


5i8 


OPERATIONS    UPON    THE    KIDNEY. 


emerge  from  the  inner  part  of  the  posterior  surface  of  the  kidney  (a  a^)  are 
separately  passed  through  the  fatty  capsule,  and  the  muscles  and  fascia  on 
the  inner  side  of  the  lumbar  wound.  These  two  ends  of  suture  are  now  tied 
together,  care  being  taken  not  to  tie  so  tightly  as  to  make  the  thread  cut  through 
the  renal  tissue.  The  result  of  the  above  manoeuvre  is  to  sling  the  kidney 
by  a  double  thread  the  outer  end  of  which  surrounds  (subperiosteally)  the 
twelfth  rib;  the  inner  end  is  fastened  to  the  muscles  and  fascia  forming  the 
inner  wall  of  the  lumbar  wound.  Two  more  double  catgut  sutures  are  passed 
through  the  kidney  in  the  same  manner  and  their  loops  cut  so  that  each  double 
suture  becomes  two  distinct  sutures  passing  through  the  kidney  together. 
The  ends  of  suture  emerging  from  the  inner  part  of  the  kidney  are  each  sep- 
arately passed  through  the  muscles  and  fascia  on  the  inner  side  of  the  wound 
(B  B^,  C  C^)  and  there  tied  together;  those  emerging  from  the  outer  part  of 
the  kidney  are  similarly  passed  through  the  muscles  and  fascia  on  the  outer 
side  of  the  wound  (c  c"^,  b  b^)  and  there  tied.  The  threads  emerging  on  the 
inner  side  are  tied  together;  none  are  tied  across  the  wound.  The  lumbar 
wound  is  closed  by  deep  and  superficial  sutures. 

Method    V    (Jonnesco's    Operation). — Step    A. — Beginning    at    the    outer 
edge  of  the  erector  spinje  muscles,  make  an  incision  from  four  to  five  inches 

along  the  inferior  border  of  the  twelfth  rib. 
If  the  twelfth  rib  is  short,  the  incision  is 
continued  along  the  eleventh  rib.  Expose 
the  whole  of  the  twelfth  and  if  necessary 
part  of  the  eleventh  rib.  Cut  through  the 
transversalis  fascia  and  expose  the  kidney, 
which  an  assistant  presses  up  into  the 
wound.  Excise  most  of  the  fatty  capsule. 
Split  the  fibrous  capsule  of  the  kidney  longi- 
tudinally and  turn  outwards  and  inwards 
an  outer  and  an  inner  capsular  tiap  (as  in 
Method    II). 

Step  B. — Pass  a  curved  needle  (Emmet's 
needle)  through  the  following  structures  in 
the  order  named — the  skin  (one  inch  distant 
from  the  lower  edge  of  the  wound),  muscles  of  sacro-lumbar  mass,  deep 
aponeurosis,  folded  inner  flap  of  renal  capsule  (formed  in  Step  A),  the  kidney 
parenchyma,  the  folded  outer  flap  of  renal  capsule,  the  periosteum  of  the 
external  surface  of  the  twelfth  or  eleventh  rib,  and  the  muscles  and  skin  of 
the  superior  edge  of  the  wound  (Fig.  609).  Thread  into  the  needle  the  end 
of  a  silver  wire  suture;  withdraw  the  needle.  Reintroduce  the  needle  in  the 
same  manner  at  a  point  1/2  inch  distant  and  pull  through  the  other  end  of 
the  silver  wire  suture.  The  result  is  that  a  U  suture  is  in  place.  Two  such 
suffice.  Through  the  loop  of  each  U  is  placed  a  small  roll  or  pad  of  gauze 
to  prevent  the  skin  being  cut.     The  other  ends  of  each  U  suture  are  twisted 


Fig.  609. 


NEPHROPEXY. 


519 


together  over  a  pad  of  gauze.     No  tension  is  put  on  the  sutures  lest  they  cut 
the  kidney  tissue;  their  function  is  to  suspend  the  kidney. 

Step  C. — Close  the  wound  with  catgut  or  silkworm-gut  sutures. 


^^^^^^^^^^^^^^^^^^^^HHL^ .      .             ^. ■.!(«?•  "5^95  -^-^    ■                          ^^^^^f^^^^^^^^^^^^^^^^k 

J 

Fig.  610. — (Edebohh,  "Annals  of  Surg") 

The  dressings  are  left  untouched  for  ten  days,  after  which  time  all  the 
non-absorbable  sutures  are  removed. 

Method  VI  (Edebohls'  Operation). — Step  i. — Expose  the  kidney  by  Method 
A,  patient  being  in  prone  position. 


Fig.  611. — (Edebohls,  '"  Annals  of  Surg.") 

Step  2. — Deliver  the  kidney  through  the  wound  and  excise  the  fatty  capsule. 
Step  3. — Decapsulate  the  kidney  anil  introduce  suspension  sutures  of  forty- 
day  chromic  gut,  as  shown  in  Fig.  610. 


520  opj:rations  upon  the  kidney. 

Step  4. — Reduce  the  kidney  and  pass  the  sutures  from  within  outwards 
through  the  whole  thickness  of  the  parietes  except  the  skin,  and  tie  them  as 
in  Fig.  611. 

Step  5. — Close  the  lumbar  w'ound. 

In  performing  this  operation  do  not  endeavor  to  anchor  the  kidney  at  as 
high  a  level  as  its  normal  site,  and  be  careful  not  to  cause  any  kinking  of  ^the 
ureter.  The  main  principle  of  the  operation  is  to  bring  a  large  area  of  decorti- 
cated kidney  into  contact  with  a  corresponding  area  of  the  quadratus  muscle 
denuded  of  its  fascial  coverings. 

Method  VII. — Albarran  ("La  Presse  Medicale,"  21  Aug.,  1906)  considers 
that   a   good   operation   must   fulfill    the    following    conditions:     (i)  Permit 


~T   ^ 

HBb     '.^  jS 

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i 

r 

1                 V 1  "^BflWII 
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0, 

^^^^^m 

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wa 

w[ 

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Ki 

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^^WIBI 

Fig.  612. 

exploration  of  the  kidney  and  ureter.  (2)  Place  the  kidney  in  good  position. 
(3)  Fix  the  kidney  thoroughly.     (4)  Injure  the  parenchyma  as  little  as  possible. 

The  Operation. — Step  i. — Expose  the  kidney  by  Method  B.  In  tearing 
through  the  perirenal  fat  it  is  not  necessary  to  remove  any  of  it,  but  when 
retracting  the  fat  from  the  lower  pole  of  the  kidney  an  incision  through  it  at 
right  angles  to  the  original  wound  is  of  great  service. 

Step  2. — Deliver  the  kidney  on  to  the  back.  Explore  it  by  sight  and  palpa- 
tion. Gross  changes  are  easily  made  out.  When  there  is  slight  hydronephro- 
sis the  kidney  is  not  so  firm  as  usual,  and  it  is  easy  to  bend  it  a  little  on  itself , 
which  is  impossible  in  the  normal  organ.  Examine  the  upper  end  of  the  ureter 
lest  kinks  or  bends  are  present  or  lest  fibrous  bands  cause  obstruction.  Correct 
abnormalities. 


NEPHROPEXY. 


521 


Step  3. — Decorticate  the  kidney  completely,  making  the  reflected  true 
capsule   form   two    flaps    (anterior   and   posterior). 

Step  4. — Divide  the  anterior  flap  into  two  parts  (upper  and  lower)  (Fig. 
612).  Ligate  each  of  these  parts  with  stong  chromicized  catgut  (Fig.  613), 
leaving  both  ends  of  the  catgut  long.  Treat  the  posterior  capsular  flap  in 
the  same  manner. 

Step  5. — Retract  the  lumbar  muscles  inwards  and  expose  the  twelfth  rib. 
With  a  needle  draw  one  end  of  each  of  the  ligatures  attached  to  the  upper  por- 
tions of  the  capsule,  round  the  rib  and  tie  it  to  the  same  end  of  the  other  ligature 
(Fig.  613).  This  suspends  the  upper  pole  of  the  kidney  to  the  rib.  One 
third  of  the  long  diameter  of  the  kidney  ought  to  be  now  hidden  by  the  ribs.  If 
it  is  impossible  to  pass  the  sutures  round  the  twelfth  rib,  fix  them  to  the  ex- 
ternal periosteum  of  the  eleventh  rib  and  to  the   costo-vertebral  ligament. 


Fig.  61^ 


Before  tying  the  sutures  see  that  the  kidney  is  so  placed  that  the  ureter  is 
free  from  kinks  and  will  drain  the  lowest  point  of  the  pelvis. 

Step  6. — Fix  the  ligatures  attached  to  the  lower  portions  of  the  capsule 
to  the  muscles  on  each  side  of  the  wound.     Fig.  614  explains  this  step. 

Step   7. — ^Provide  for   drainage — close   the   wound   with   sutures. 

In  all  the  preceding  methods  of  nephropexy  the  aim  of  the  surgeon  has 
been  to  suture  or  sling  the  kidney  to  the  posterior  parietes.  Harris  has  shown 
that  in  cases  of  mobfle  kidney  there  is  a  separation  of  the  posterior  peritoneum 
from  the  parietes,  and  that  the  attachments  of  the  ascending  mesocolon  are 
loosened.  The  result  is  an  absence  of  normal  support  to  the  kidney  and 
the  presence  of  ptosis  of  the  ascending  colon. 


522 


OPERATIONS    UPON    THE    KIDNKY. 


Harris'  Operation. — Place  the  patient  in  the  prone  position;  expose  the 
kidney  and  bring  it  out  through  the  wound.  Retract  the  edges  of  the  wound 
and  observe  the  post-peritoneal  cavity  into  which  the  kidney  has  been  in 
the  habit  of  gliding  and  note  the  position  of  the  ascending  colon.  By  a  few 
carefully  placed  catgut  sutures  obliterate  the  abov.e-named  space,  and  the 
essential  element  of  the  Harris  operation  is  completed.  Prepare  the  kidney 
for  suture,  reduce  it,  and  fix  it  to  the  parietes  by  one  of  the  methods  already 
described. 

The  Harris  operation  is  the  only  one  in  which  any  attention  is  paid  to  the 
fact  that  nephroptosis  is  often  merely  one  part  of  a  condition  of  general  visceral 
ptosis,  and  in  which  an  endeavor  is  made  to  correct  part  of  the  visceral  ptosis 


Fig.  614. 

by  fixation  of  the  colon  (colopexy)  while  the  post-peritoneal  space  is  being 
obliterated. 

Mobile  kidney  is  exceedingly  common,  and  in  the  majority  of  cases  presents 
no  symptoms.  When  symptoms  are  present,  they  may  be  really  those  of 
neurasthenia,  in  which  case  fixation  of  the  kidney  can  scarcely  be  expected 
to  do  more  than  give  mental  relief.  Of  course,  cases  do  occur  in  which  the 
mobility  of  the  kidney  is  the  causative  factor,  where  tension  exerted  on  the 
structures  at  the  hilus  gives  rise  to  trouble  and  where  kinking  or  displace- 
ments of  the  ureter  occasion  distressing  symptoms  and  conditions.  It  is  in 
this  comparatively  small  class  of  cases  that  nephrorrhaphy  gives  gratifying 
results. 

Alglave  ("Rev.  de  Chir.,"  Dec,  1904)  describes  a  number  of  cases  in 
which  ptosis  of  the  kidney  led  to  a  descent  of  the  upper  part  of  the  ascending 


NEPHROPEXY. 


523 


colon,  the  aocum  remaining  fixed.  The  resuh  of  this  is  an  abnormal  flexing 
of  the  gut,  with  dilatation  and  most  obstinate  constipation.  Colitis  and 
pericolitis  are  commonly  present,  with  many  adhesions.  According  to  Al- 
glave,  these  accidents  are  secondary  to  the  nephroptosis,  but  are  often  so 
thoroughly  established  that  nephropexy  is  insufficient  to  correct  them.  The 
author  has  met  this  condition  in  a  number  of  cases  and  has  seen  fair  results 
follow  liberation  of  the  gut  from  its  adhesions.  In  bad  cases  exclusion  of 
the  ascending  colon  by  uniting  the  ileum  to  the  descending  colon  (see  "In- 
testinal Exclusion")  will  be  found  serviceable. 


;.  mm. 


7>.    '-^^vj 


-r^  •.^,, 


C^AAuni/:-. 


5i...e 


,,»,i^r».' 


Fig.  615. — iBroedel.) 

Many  surgeons,  when  operating  on  the  right  side,  before  proceeding  to 
treat  the  kidney  itself  in  the  operation  of  nephrorrhaphy,  open  the  peritoneum 
freely,  find  the  ascending  colon,  draw  it  out  of  the  wound,  and  follow  one 
of  its  longitudinal  bands  to  the  appendix.  Excise  the  appendix  whether 
diseased  or  not.  In  the  hands  of  an  expert  this  additional  step  consumes 
only  a  very  few  minutes,  and  as  one  eminent  surgeon  remarked  to  the  writer, 
"'If  any  operator  ever  gets  close  to  my  appendix,  I  would  never  forgive  him 


524 


OPERATIONS    UPON    THE    KIDNEY. 


should  he  not  remove  it."  The  same  surgeons  who  advocate  appendicectomy 
as  a  step  in  the  operation  also  advocate  exploration  of  the  biliary  passages 
as  a  routine  measure.  The  inexperienced  operator  is  advised  not  to  add 
the  above-mentioned  steps  to  the  operation  of  nephropexy,  as  in  his  hands 
the  extra  risk  incurred  will  probably  more  than  balance  the  benefits  which 
may   accrue. 

To  understand  the  advantages  and  disadvantages  of  the  various  methods 
of  exploring  the  kidney  and  of  removing  calculi  from  it,  a  thorough  knowledge 
of  its  surgical  anatomy  is  essential.  The  descriptions  given  in  many  of  the 
text-books  of  anatomy  are  entirely  insufficient  for  practical  use  at  the  operat- 
ing table.  Of  course  when  a  kidney  is  the  site  of  a  large  collection  of  fluid, 
whether  purulent  or  not,  it  can  be  incised  and  drained  or  excised  without 
necessitating  any  exact  anatomical  knowledge  on  the  part  of  the  surgeon.  The 
same  is  true  when  very  large  calculi  are  present.     In  such  cases  after  ex- 


P    j^  s      t 


Fig.  6i6. — {Broedel.) 


posure  of  the  kidney  no  real  exploration  is  required;  the  indications  for  treat- 
ment are  fairly  evident.  When  it  is  necessary  really  to  explore  the  kidney  and 
its  pelvis,  precise  anatomical  knowledge  is  essential. 

The  kidney  may  be  taken  to  be  composed  of  a  number  of  conical  masses 
of  parenchyma,  the  secreting  tubules  of  which  open  on  the  nipple-like  apices 
of  the  cones.  These  cones  of  parenchyma  are  fused  together  into  one  mass 
in  such  fashion  that  the  apices  of  the  cones  present  into  a  cavity  (sinus  of  the 
kidney)  completely  surrounded  by  parenchyma  except  at  the  inner  or  convex 
border  of  the  organ  where  the  sinus  or  cavity  is  open  (hilum).  (Figs.  615  and 
616.)  The  ureter  is  a  tube  which  runs  from  the  bladder  up  to  the  kidney. 
When  the  ureter  comes  near  the  hilum  of  the  kidney  it  expands  to  form  a  cavity 
of  varying  size,  the  pelvis  of  the  kidney.  The  pelvis  of  the  kidney  extends 
into  the  sinus  of  the  kidney  and  may  be  of  several  types. 

(A)  A  number  of  short  tubes  may  be  given  off  from  the  pelvis,  and  into 
the  open  expanded  end  of  each  of  these  tubes  (calyx)  the  apex  of  a  renal  cone 


ANATOMY. 


525 


is  inserted  like  an  acorn  in  its  cup,  so  that  the  urine  escaping  from  the  renal 
tubujes  flows  into  the  pelvis  and  so  into  the  ureter.  This  is  the  so-called  classical 
or  ampullary  type  (Fig.  617)  and  occurs  in  about  30  per  cent,  of  cases  observed 
by  Delbet  and  Mocquot.  ("Rev.  de  Gyn.  et  de  Chir.  Abdominale,"  xi,  No. 
4,  1907.)  The  tubes  leading  from  the  calices  to  the  pelvis  are  very  short, 
sometimes  so  short  that  the  apex  of  the  cone  may  protrude  into  the  pelvis 
itself. 

(B)  Ramifying  Type  of  Pelvis. — Just  inside  the  opening  of  the  sinus 
of  the  kidney  the  pelvis  may  divide  into  tubes  (primary  tubes) ;  these  in  turn 
may  give  ofif  secondary  tubes  the  open  ends  of  which  form  the  calices.     The 


Fig.  617. — -Ampullar}' Type  Pelvis.     {Delbet  and  Mocquot.) 


division  of  the  pelvis  may  be  (a)  Bind- — one  primary  tube  going  to  the  upper 
pole  of  the  kidney,  the  other  to  the  lower  pole,  {b)  Trifid — where  the  third 
tube  goes  horizontally  to  collect  urine  from  the  middle  portion  of  the  kidney. 
A  glance  at  Figs.  617,  618,  619  will  explain  the  foregoing  remarks.  The 
pelvis  of  the  kidney  and  its  tributary  tubes  are  attached  to  the  inside  of  the 
sinus  of  the  kidney  merely  by  loose  connective  tissue  and  fat.  There  are 
no  openings  in  the  pelvis  or  its  tributaries  except  the  calices  and  these  are 
plugged  by  the  nipple-like  apices  of  the  renal  cones.  Thus  the  collecting 
apparatus  (pelvis,  tubes,  calices)  is  entirely  distinct  from  the  secreting 
apparatus  (the  kidney)  although  it  is  usually  almost  entirely  hidden  within 
the  kidney  sinus.  The  notion  is  important  as  it  shows  that  no  exploration 
of  the  pelvis  is  possible  by  nephrotomy  without  incision  of  the  pelvis,  i.  e., 
without  pyelotomy.  The  renal  artery  reaches  the  hilum  of  the  kidney  at 
a  higher  level  than  the  pelvis  and  here  divides  into  three  or  four  branches 


526 


OPERATIONS    UPON    THE    KIDNEY. 


(Fig.  620),  one  of  which  passes  over  the  upper  border  of  the  pelvis  and  passes 
downwards  on  the  posterior  surface  of  the  origin  of  the  primary  tubes 
(Fig.  621).  This  branch  usually  lies  well  inside  the  sinus,  but  it  may  be 
situated  along  the  opening  of  the  sinus  (the  hilum). 

The  renal  artery  or  its  branches  as  soon  as  they  enter  the  hilum  lie  in 
contact  with  the  kidney  parenchyma  to  which  they  give  off  branches.  They 
are  separated  from  the  pelvis  and  its  collecting  tubes  by  loose  fatty  connective 
tissue  and  in  the  living  body,  where  the  tissues  are  much  more  supple  than 


Fig.  618.— Trifid  Pelvis.     {Delbet  and  Mocquol.) 


Fig.  619. — Bifid  Pelvis.     (Delbet 
and  Mocquot.) 


in  the  cadaver,  they,  plus  the  renal  cortex  bordering  the  sinus,  can  be  readily 
retracted  from  the  pelvis  and  from  part  of  the  tubes  (Delbet  and  Mocquot). 

The  arteries  in  their  distribution  do  not  loop  themselves  round  the  calices. 
One  must  remember  that  one  or  more  branches  of  the  renal  artery  may  enter 
the  kidney  through  its  cortical  substance,  away  from  the  hilum  and  require 
separate  attention  during  nephrectomy. 

The  renal  vein  and  its  branches  lie  between  the  artery  and  the  collecting 
apparatus  (pelvis,  tubes,  calices).  They  are  as  loosely  connected  with  the 
latter  structures  as  are  the  arteries,   except  that  venous  anastomoses  occur 


ANATOMY. 


527 


Fig.  620. — (Poirier  and  Charpey.) 


Fig.  621. 


528 


OPERATIONS   UPON   THE    KIDNEY. 


around  the  calices  (Figs.  622  and  623).  In  the  fatty  tissue  of  the  renal  sinus 
lie  the  lymphatics  and  nerves  of   the  kidney. 

From  the  preceding  paragraphs  it  might  seem  that  the  sinus  of  the  kidney 
was  always  the  same  shape  and  bore  the  same  relationship  to  the  pelvis.  This 
would  be  far  from  the  truth. 

Fig.  624  shows  a  kidney  in  which  there  is  little  notching  of  the  inner  border 
of  the  kidney  and  in  which  most  of  the  renal  pelvis  lies  in  an  accessible  position, 
i.  e.,  not  inside  the  sinus.     Fig.  625  shows  a  very  different  arrangement  in 


,<^«rn^' 


T  ^^ 


Fig.  622. — (Broedel.) 


which  the  sinus  opens  at  the  bottom  of  a  deep,  acute-angled  notch.  The 
pelvis  is  small  and  is  almost  completely  contained  within  the  notch  and  the 
sinus.     Between  these  two  varieties  there  are  all  sorts  of  gradations. 

Exploration  of  the  Kidney. — Expose  the  kidney,  preferably  by  Method  A, 
with  the  patient  in  the  prone  position.  By  pulling  upon  the  fatty  capsule  and 
by  pressing  on  the  abdomen  with  the  hand,  bring  the  kidney  into  the  wound 
and  deliver  it  on  to  the  back,  where  it  may  be  palpated  and  inspected  thoroughly. 


EXPLORATION    OF    KIDNEY. 


529 


Should  it  be  impossible  to  safely  deliver  the  organ  (because  of  adhesions, 
etc.)   separate  it  by  blunt  dissection  from  its  surroundings,  except,  of  course, 


Fig.  62 ^.—{Broedel.) 


Fig.   624. — (Delbet  and  Mocquot.) 

at  the  hilus,  when  its  whole  surface  and  pelvis  may  be  palpated.     Should 
the  presence  of  calculi  be  suspected,   but  not  be  determined  by  palpation, 
34 


53©  OPERATIONS    UPON    THE    KIDNEY. 

it  is  often  advised  to  perforate  the  organ  in  all  directions  with  a  fine  round 
needle  (lady's  hat-pin).  Whenever  the  needle  touches  a  calculus,  a  sensa- 
tion of  grating  is  communicated  to  the  hand.  Should  a  cyst  of  the  kidney 
be  discovered,  its  contents  may  be  obtained  for  examination  by  means  of  the 
exploring  needle  and  syringe. 

The  above  exploration  of  the  kidney  often  fails  to  give  the  information 
desired,  and  further  investigation  is  necessary. 

Exploration  of  the  Renal  Pelvis  Without  Pyelotomy.  Delbet's 
Method. — Expose  the  kidney  through  the  lumbar  route,  deliver  it  on  to  the 
back  and  place  it  so  that  its  posterior  surface  is  exposed  to  view  and  touch. 


Fig.   625. — [Delhet  and  Morqiwt.) 

Beginning  at  its  ureleral  end,  free  the  posterior  surface  of  the  renal  pelvis 
from  its  covering  of  loose  fatty  areolar  tissue  by  blunt  dissection.  Push 
aside  the  areolar  tissue  and  retract  it,  very  gently,  along  with  the  blood-vessels 
and  the  parenchyma  forming  the  wall  of  the  sinus.  The  same  dissection  may 
be  made,  if  necessary,  on  the  anterior  surface  of  the  pelvis.  By  this  means 
most  of  the  pelvis,  often  all  of  it,  and  sometimes  the  beginning  of  the  primary 
tubes  may  be  exposed  to  view.  It  is  now  possible  to  pass  the  finger  into 
the  sinus  behind  the  pelvis  without  tearing  anything  and  thus  directly  palpate 
the  pelvis.  The  finger  can  be  introduced  in  the  middle  transverse  diameter 
of  the  kidney  to  the  bottom  of  the  sinus  and  can  palpate  the  middle  calices; 


NEPHROTOMY. 


531 


KIDNEY 


towards  the  upper  and  lower  poles  it  cannot  be  introduced  so  far,  but  it  can 
always  explore  a  considerable  portion  of  the  upper  and  lower  primary  tubes. 

Delbet's  method  permits  useful  accurate  palpa- 
tion without  danger;  the  ordinary  methods  of 
palpation  unaccompanied  by  the  dissection  de- 
scribed are  clumsy  and  only  calculated  to  reveal 
gross  lesions. 

Nephrotomy. — Step  i. — Expose  and  isolate 
the  kidney  as  in  the  operation  of  exploration. 

Step  2. — Deliver  the  kidney  on  to  ihe  patient's 
back.  Surround  the  hilus  or  pedicle  with  a 
rather  fine  rubber  band  or  tube  not  too  tightly 
applied,  and  fastened  by  tape  and  forceps,  as 
shown  in  Fig.  626.  This  renders  the  next  step 
practically  bloodless,  but  entirely  prevents  ex- 
ploration of  the  ureters.  An  intestinal  clamp  with 
rubber  covered  blades  serves  the  same  purpose. 
Instead  of  using  the  rubber  constrictor,  an  assis- 
tant may  control  the  circulation  with  finger  pres- 
sure applied  to  the  hilus,  or  no  control  of  the 
circulation  may  be  attempted.  In  some  cases  it 
is  impossible  to  deliver  the  kidney  safely.  Under 
these  circumstances  hook  the  finger  in  front  of 
the  organ  and  bring  its  convex  margin  as  well 
as  possible  into  the  wound. 

Step  3. — Grasp  the  kidney  between  the  fingers  and  thumb  of  the  left  hand 
and  make  a  longitudinal  cut  along  its  convex  border  of  such  size  and  depth 
that  the  finger  may  be  passed  into  the  renal  pelvis.     If  necessary,  the  kidney 


Fig.  626. 
R.  Rubber  tube  or  band. 
T.  Tape  placed  over  the  cross- 
ing-point of  rubber  tube,  and 
held  by  forceps.  It  is  just  as 
good  to  fix  the  rubber  by  the 
forceps  without  the  use  of  the 
tape. 


Jiubber-  Tissue 


Fig.  627. — {Mmwd  and  Vanverts.) 


Fig.  628. 


may  be  spilt  open  throughout  its  whole  length,  as  is  done  at  the  postmortem 
table  (Fig.  627).  Introduce  the  finger  through  the  wound  and  palpate  the 
interior  of  the  kidney  and  its  pelvis;  the  fingers  of  the  other  hand  applied 


532 


OPERATIONS    UPON    THE    KIDNEY. 


to  the  surface  of  the  organ  aid  this  exploration.  If  the  elastic  constrictor 
has  not  been  employed  or  after  its  removal,  the  ureters  may  be  examined  by 
ureteral  catheters  or  bougies  passed  through  the  wound.  To  obviate  this 
trouble  it  is  proper  to  apply  the  constrictor  to  the  vessels  alone.  When  the 
active  examination  or  operation  is  completed,  close  the  renal  wound  with  a 
few  catgut  sutures  introduced  by  a  round  needle,  i.  e.,  one  without  cutting 

edges.  The  sutures  stop  all  hemorrhage. 
Close  the  lumbar  wound,  in  layers,  with 
buried  sutures  or  with  through-and- 
through  sutures  of  silkworm-gut.  Pro- 
vide for  drainage  if  necessary.  This 
may  be  accomplished  by  placing  a  few 
layers  of  folded  rubber  tissue  over  the 
line  of  suture,  and  tying  the  ends  of  the 
catgut  sutures,  left  long  for  this  purpose, 
over  the  tissue  (Fig.  628). 

The  above  is  the  classical  method  of 
performing  nephrotomy,  but  it  takes  no 
cognizance  of  the  arrangements  of  vessels 
inside  the  kidney  and  hence  may  destroy 
an  unnecessary  number  of  important 
vessels,  thus  cutting  off  nutriment  from 
and  causing  necrosis  of  an  unnecessary 
amount  of  cortex. 

The  arteries  are  distributed  to  the 
cortex  in  two  groups — an  anterior  and  a 
posterior  group.  The  anterior  vascular 
region  is  wider  than  the  posterior.  Ac- 
cording to  Broedel,  the  line  bb^  (Figs. 
629  and  630)  overlies  the  principal  vessels 
of  the  kidney  parenchyma  and  in  lobu- 
lated  kidneys  is  marked  by  a  distinct 
depression  on  the  surface,  over  which  the 
capsule  seems  thickened,  forming  a 
whitish  band  to  which  the  perirenal  fat  may  be  more  adherent  than  elsewhere. 
An  incision  (cc'),  just  posterior  to  the  lateral  convex  border  of  the  kidney 
(aa^)  gives  good  access  to  the  posterior  group  of  calices  and  injures  the  fewest 
possible  vessels. 

CuUen  and  Derge  split  the  kidney  by  passing  a  long,  blunt,  flat  needle 
through  it  from  pole  to  pole  and  by  means  of  this  needle  introduce  a  fine  silver 
wire  of  low  tensile  strength.  A  see-saw  motion  given  to  the  wire  permits 
it  to  cut  its  way  out  of  the  kidney  without  causing  bleeding.  The  method  is 
identical  with  that  used  by  potters  to  cut  clay.  In  kidneys  where  disease  has 
caused  the  formation  of  areas  of  fibrous  tissue  so  much  pressure  must  be  put 


Fig.   296. — (Broedel.) 


NEPHROTOMY.  533 

on  the  wire  that  the  resulting  trauma  occasions  more  bleeding  than  would  be 
caused  by  the  use  of  the  knife  (E.  H.  Richardson). 

Marwedel's  Nephrotomy. — Expose  the  kidney  by  the  lumbar  route. 
Deliver  it  on  to  the  back.  At  the  middle  of  the  convex  border  of  the  kidney 
make  a  transverse  incision  through  the  parenchyma  into  the  pelvis.  Intro- 
duce the  finger  to  explore.  If  more  room  is  required  enlarge  the  incision  both 
anteriorly  and  posteriorly  until  the  kidney  is  divided  into  an  upper  and  lower 
half.  It  is  now  easy  to  so  open  the  wound  that  the  pelvis  becomes  very  access- 
ible. Marwedel  claims  his  operation  (a)  unusually  free  access  to  the  renal 
pelvis;  {h)  less  destruction  of  parenchyma;  (c)  less  injury  to  important  blood- 
vessels and  consequently  less  necrosis  of  parenchyma.  Zondek  shows  that 
injury  to  blood-vessels  is  quite  as  great  as  in  the  longitudinal  incision.     WTien 


Fig.  630. — (Broedel.) 

the  renal  pelvis  is  of  the  ampullary  type  (30  per  cent.)  undoubtedly  Marwedel's 
method  will  give  perfect  access  to  it,  but  when  the  pelvis  is  of  the  ramifying 
variety  the  state  of  affairs  is  very  different  and  the  exposure  may  be  practi- 
cally nil. 

When  nephrotomy  is  performed  as  a  therapeutic  measure,  complete  closure 
of  the  renal  and  lumbar  wounds  is  almost  always  improper.  Drainage  must 
be  provided.     Drainage  may  be  accomplished  as  follows: 

(a)  Introduce  a  wick  of  mildly  iodoformized  gauze,  surrounded  by  rubber 
tissue  (cigarette  drain),  into  the  portion  of  kidney  to  be  drained  and  fix  it 
there  by  a  stitch  of  plain  catgut  or  tie  the  ends  of  one  of  the  renal  sutures  around 
the  drain  (Fig.  631).  This  simple  precaution  is  perfectly  harmless  and  pre- 
vents displacement  of  the  drain.  A  drain  of  folded  rubber  tissue  or  oil-silk 
without  any  gauze  is  probably  better  than  the  cigarette  as  gauze  adheres  to  the 
tissues  and  may  favor  the  formation  of  fistula.  It  is  wise  to  leave  the  drain 
in  situ  for  a  week  or  longer. 

(b)  Use  in  the  same  manner  a  rubber  tube  split  longitudinally  and  contain- 
ing a  wick  of  gauze.  The  split  runs  the  whole  length  of  the  tube,  diminishing 
its  rigidity  and  thus  avoiding  some  possibilities  of  injury  to  tissues  from  pressure. 


534 


OPERATIONS    UPON    THE    KIDNEY. 


Gauze 
Jiubher  Tif-Biie 


Do  not  insert  the  tube  too  deeply,  as  it  may  then  cause  much  pain,  and  even 
reflex  anuria. 

(r)  In  the  same  manner  use  and  fix  in  place  a  dressed  rubber  tube  (Fig.  632). 
If  the  kidney  is  the  seat  of  multiple  abscess  and  nephrectomy  is  not  indicated, 

open  all  the  abscesses  freely,  either  through 
the  original  renal  incision  or  through  indi- 
vidual incisions,  as  may  be  convenient.  If  it 
is  believed  that  relief  of  tension  may  be  of 
value  in  a  case  where  nephrotomy  has  re- 
vealed no  pathological  condition  sufficient  to 
account  for  the  symptoms,  then  it  is  wise  to 
leave  the  renal  wound  at  least  partly  open. 
A.  H.  Ferguson,  Edebohls,  and  others  practise 
decortication  of  the  kidney  when  they  desire 
to  relieve  tension  in  cases  of  nephritis.  Their 
operation  for  nephritis  consists  in  exposure, 
delivery,  and  decortication  of  the  kidney.  Excellent  reports  have  been  pub- 
lished as  to  the  success  of  decortication  in  nephritis,  but  the  whole  question  is 
still  suh  judice.     Wounds  of  the  kidney  heal  rapidly  when  sutured. 

F.  S.  Watson  ("Annals  of  Surg.,"  Dec,  1905;  March,  1906;  Sept.,  1907) 
recommends  double  nephrostomy  to  take  the  place  of  ureteral  implantations: 
(i)  as  a  palliative  measure  in  cases  of  inoperable  vesical  tumor  or  of  vesical 
tuberculosis  causing  suffering  where  the  infection 
is  descending  and  both  kidneys  are  involved;  (2) 
as  a  preliminary  to  total  extirpation  of  the  blad- 
der. After  the  kidney  is  exposed  and  incised,  the 
ureter  is  ligated  as  near  the  renal  pelvis  as  possi- 
ble. When  the  urinary  fistula  is  established,  place 
over  (not  into)  it  a  cupshaped  shield  or  funnel 
connected  with  a  metallic  receptacle.  The  re- 
ceptacle can  be  conveniently  emptied  even  in  a 
public  urinal  by  means  of  a  rubber  tube  (Fig.  633). 
Rovsing  instead  of  nephrotomy  practises  lum- 
bar ureterostomy  as  a  part  of  complete  cystectomy 
(see  cystectomy).  Wilms  (of  Basel)  exposes  the 
ureter  at  the  brim  of  the  pelvis,  preferably  extra- 
peritoneally,*  and  brings  it  out  of  the  wound 
about  2  inches  above  the  anterior  superior  spine 
of  the  ilium.  If  the  ureteral  stump  is  long  enough 
it  is  well  to  pass  it  through  a  subcutaneous  tunnel 
for  a  distance  of  i  1/2  to  2  inches.  After  the  wound  has  healed  it  is  easy  to  cut 
the  skin,  under  which  the  ureter  runs,  in  the  form  of  a  flap  and  so  to  envelop 
the  ureter  in  the  flap  of  skin  as  to  form  a  convenient  spout  (Fig.  634). 
*  For  exposure  of  ureter  see  Ureterotomy. 


NEPHROLITHOTOMY.  535 

Nephrolithotomy. — Expose  and  if  possible  deliver  the  kidney  as  in  neph- 
rotomy. Control  the  renal  circulation  by  linger  pressure  at  the  hilus  or  by  the 
elastic  constrictor,  if  this  is  feasible.  Incise  the  kidney  as  in  nephrotomy. 
If  the  stone  is  small  and  lies  free  in  the  pelvis,  pass  a  forceps  through  the  renal 
wound  and  extract  it.  When  the  stone  is  large  and  fills  the  renal  calices,  its 
extraction  becomes  a  matter  of  great  difficultv.     Under  such  circumstances  en- 


V\c,.   ()^^3. — (Watson,  .liinals  Surg.) 

large  the  incision  through  the  kidney  to  the  necessary  extent.  With  the  finger, 
peel  the  stone  out  of  the  calices  and  remove  it  unbroken.  If  its  removal  entire 
is  impossible  fracture  it  with  forceps,  but  let  the  fragments  be  as  few  in  number 
as  possible.  If  there  are  many  and  small  fragments,  some  of  them  are  liable 
to  escape  extraction  and  cause  trouble  in  the  future.  Remove  all  debris, 
with  finger,  spoon,  forceps,  gauze  strips,  or  douche.  WTien  several  calculi 
are  present,  they  may  often  be  extracted  through  the  same  renal  wound,  but  if 


yi> 


536  OPERATIONS    UPON    THE    KIDNEY. 

more  convenient,  they  may  be  removed  through  separate  incisions.  It  is  far 
less  damaging  to  the  kidney  to  make  several  clean  incisions  through  its  paren- 
chyma and  thus  extract  the  calculi  with  the  minimum  of  laceration  and  con- 
tusion than  to  endeavor  to  take  them  all  out  through  one  cut.  The  latter- 
plan  too  often  results  in  the  kidney's  being  converted  into  ragged  mass  lying 
inside  a  nearly  perfect  capsule. 

The  calculi  having  been  removed,  introduce  and  fix  drains  in  the  renal 
wounds,  as  has  been  described  under  the  heading  Nephrotomy.  Close  the 
nephrotomy  wounds  as  far  as  necessary  with  catgut.     Close  the  lumbar  wound 

except  where  the  drains  emerge.  A  stone 
weighing  four  and  one-half  ounces  has  been 
removed  in  the  above  manner. 

Pyelotomy  and  Pyelolithotomy. — The 
kidney  is  exposed  and  if  possible  delivered  aftei 
the  methods  already  described.  The  pelvis  of 
the  kidney  is  incised.  The  incision  should  not 
be  located  too  near  the  renal  parenchyma,  for 
the  following  reasons  (Israel):  (i)  In  this  loca- 
tion sutures  are  inserted  with  difficulty  and  are 
liable  not  to  hold.  (2)  When  a  stone  is  being 
Fig.  634.  extracted  through  such  a  cut,  the  renal  paren- 

chyma may  be  injured,  resulting  in  hemorrhage 
and  subsequently  renal  colic  from  the  blood-clots  formed  in  the  pelvis  and 
ureter.  After  the  stone  is  extracted,  the  pelvic  wound  is  to  be  closed  by  a 
few  catgut  sutures  unless  drainage  of  the  pelvis  is  demanded.  Wounds  of 
the  pelvis  of  the  kidney  heal  readily  when  infection  is  absent.  The  Mayos 
find  that  closure  without  leakage  may  be  secured  even  if  the  suture  of  the  pelvis 
is  very  imperfect  provided  the  pelvic  wound  is  covered  by  a  flap  of  fatty  fascia. 
In  nephro-lithiasis  there  is  often  a  distinct  increase  in  the  amount  of  fatty 
tissue  attached  to  the  pelvis.  If  it  is  possible  to  make  the  pelvic  incision 
through  this  fat  do  so,  and  after  suturing  the  pelvic  wound,  close  the  fatty  wound 
separately  with  fine  catgut.  If  the  pelvic  wound  is  too  large  or  irregular  or 
if  the  fat  does  not  naturally  cover  it,  it  is  easy  to  make  a  flap  of  fatty  tissue  from 
the  neighborhood,  lay  this  flap  over  the  wound  and  keep  it  in  position  by  a 
few  fine  catgut  stitches.  The  lumbar  wound  should  be  drained  by  means  of 
folded  rubber  tissue  or  oil-silk. 

Delbet's  Pyelotomy. — "This  may  be  necessary  to  permit  complete  ex- 
ploration of  the  superior  and  inferior  calices,  to  extract  a  calculus  or  to  remove 
false  membranes  which  are  sometimes  present  in  cases  of  pseudo-membranous 
pyelitis.'!  Make  an  incision  through  the  middle  of  the  posterior  surface  of  the 
pelvis  in  the  long  axis  of  the  pelvic  funnel.  Do  not  let  the  incision  involve 
the  ureter,  as  this  might  cause  stricture.  In  almost  every  case  it  is  possible  to 
make  a  cut  large  enough  to  admit  the  little  finger  and  with  it  to  explore  all  the 
tubes  and  calices.     A  fine  scoop  may  be  used  to  reach  parts  inaccessible  to  the 


NEPHRECTOMY.  537 

finger.  If  a  pelvis  is  too  small  to  permit  of  this  incision  and  exploration,  it  is 
fairly  safe  to  assume  that  it  is  healthy  and  contains  no  foreign  body.  After 
completing  the  exploration,  close  the  wound  with  fine  catgut  sutures;  if  silk  is 
used  the  suturing  must  be  of  the  Lembert  type.  Delbet  uses  two  layers  of 
suture;  the  first,  of  fine  catgut,  penetrates  the  whole  thickness  of  the  pelvic  wall, 
the  second,  of  silk,  is  introduced  in  the  Lembert  fashion  and  does  not  penetrate 
into  the  pehdc  cavity.  Simple  suture  with  catgut  is  all  that  is  really  necessary, 
the  supplemental  sutures  of  silk  do  more  harm  than  good. 

Comparative  Advantages  or  Disadvantages  of  Pyelolithotomy  and 
Nephrolithotomy  (Rovsing). — Pyelolithotomy. — Advantages:  Little  hemor- 
rhage and  no  injury  to  renal  parenchyma.  Disadvantages:  Stones  in  the 
calices  caimot  be  removed.     Fistulse  are  liable  to  result  and  persist. 

Nephrolithotomy:  By  means  of  this  procedure  all  stones  can  be  removed. 
When  no  suppuration  exists  the  renal  wound  may  be  closed  and  heal  per 
primam.  If  pus  is  present,  the  wound  may  be  partially  closed  and  drainage 
provided.  Fistulas  when  they  occur  are  more  readily  closed  than  after  pyelot- 
omy.  In  many  cases  the  hemorrhage  which  may  occur  is  not  of  importance. 
Hemorrhage  would  be  dangerous  in  patients  weakened  by  prolonged  disease 
or  in  cases  where  it  is  necessary  to  split  the  kidney  throughout  its  whole  length 
in  order  to  remove  a  very  large  stone,  were  it  not  that  the  renal  vessels  may  be 
readily  controlled  by  the  finger  pressure  or  the  elastic  constrictor.  The  injury 
to  the  parenchyma  inevitably  incurred  is  of  comparatively  little  importance. 

The  above  are  Rovsing's  views,  and  his  opinions  always  command  respect. 
The  experiments  of  Delbet  and  Mocquot  show  that  it  is  much  easier  to  reach 
every  calyx  in  the  search  after  small  calculi  by  means  of  pyelotomy  than  by 
nephrotomy. 

John  Clay  ("Brit.  Med.  Joum.,"  May  i,  1909)  recommends  the  following 
procedure  in  cases  of  double  nephro-lithiasis  where  there  is  much  destruction 
of  renal  tissue. 

Operation. — Expose  the  kidney  through  the  loin.  Open  the  peritoneum 
and  palpate  the  opposite  kidney  to  make  sure  of  its  condition.  Close  the  perit- 
oneal wound.  Deliver  the  kidney  on  to  the  back.  Loosely  pack  with  gauze 
the  cavity  from  which  it  was  removed.  Extract  the  stones  from  the  pelvis  and 
calices.  Attend  to  hemostasis.  Wrap  the  kidney  in  gauze  and  let  it  lie  on 
the  patient's  back  draining  into  the  dressings  instead  of  into  the  loose  retro- 
peritoneal tissues. 

Operation  2. — As  soon  as  the  kidney  is  covered  with  healthy  granulation 
tissue,  replace  it  in  its  normal  bed  and  close  the  wound  after  providing  for 
drainage. 

After  a  proper  lapse  of  time  the  second  kidney  may  be  treated  in  a  similar 
manner. 

Partial  Nephrectomy. — Experiment  and  experience  show  that  wounds  of 
the  kidney  heal  readily  and  that  large  parts  of  the  normal  kidney  may  be  removed 
without  noticeable  ill  effect.     Tuffier's  experiments  seem  to  show  that  one- 


538  OPERATIONS    UPON    THE    KIDNEY. 

third  or  one-fourth  of  the  kidney  is  suflEicient  for  the  performance  of 
function. 

The  kidney  is  exposed  and  delivered  through  any  of  the  incisions  already 
described.  The  diseased  portion  of  the  organ  is  removed,  if  possible,  by  a  V- 
shaped  incision,  so  that  the  resulting  wound  may  be  easily  closed  by  catgut 
sutures.  This  typical  removal  is  often  improper,  as  by  it  too  much  healthy 
parenchyma  might  have  to  be  sacrificed.  For  disease  involving  the  upper  or 
lower  ends  of  the  kidney  a  transverse  incision  may  suffice  and  sacrifice  the  least 
possible  amount  of  healthy  parenchyma.  In  the  case  of  irregular  multiple  but 
localized  abscesses,  where  neither  the  V  nor  the  transverse  incision  may  be 
applicable,  the  surgeon  contents  himself  with  scraping  and  cutting  away  all  the 
diseased  tissue.  Hemorrhage  is  prevented  after  the  last  two  operations  partly 
by  judiciously  applied  sutures  and  partly  by  gauze  packing.  For  the  packing  to 
be  effectual  it  may  be  necessary  to  stitch  the  kidney  to  the  lumbar  wound. 
The  lumbar  wound  is  closed  completely  or  in  part,  as  already  described. 

Cases  Suitable  for  Partial  Nephrectomy. — Benign  neoplasms,  e.  g.,  echinococ- 
cic  cysts,  pyonephritic  disease,  etc.  Note,  however,  that  hypernephromata 
often  appear  distinctly  encapsulated  and  easily  removed  by  partial  nephrec- 
tomy, and  yet  they  are  very  malignant  in  character.* 

Nephrectomy.- — (A)  Lumbar  Route.- — The  kidney  is  exposed  by  one  of  the 
incisions  described. 

I.  Nephrectomy  for  malignant  disease:  A  good  rule  to  adopt  when  operating 
for  malignant  disease  is  to  remove  too  much  rather  than  too  little.  The  same 
principles  which  obtain  in  excision  of  the  breast  obtain  in  nephrectomy  for 
malignant  disease. 

Step  I. — Expose  kidney  freely. 

Step  2. — With  finger  dissection  separate  the  kidney  from  its  surroundings 
until  it  is  left  attached  by  its  pedicle  alone.  If  the  organ  has  become  firmly 
adherent  to  its  surroundings,  it  may  be  easier  to  separate  the  kidney  from  its 
fibrous  capsule  (capsula  propria)  than  from  the  fatty  capsule.  In  such  a  case 
the  fibrous  capsule  may  be  left  to  be  treated  at  a  later  stage  of  the  operation. 

Step  3. — The  pedicle  is  examined.  The  vessels  and  the  ureter  are  recognized. 
A  ligature  carrier  is  passed  between  the  ureter  and  the  vessels  and  a  double 
ligature  of  silk  or  reliable  catgut  pulled  through.  One  of  the  ligatures  is  placed 
around  the  vessels  and  tied  tightly  at  as  great  a  distance  from  the  kidney  as 
possible.  This  is  to  permit  division  of  the  pedicle  far  enough  away  from  the 
ligature  to  leave  a  stump  of  length  sufi&cient  to  prevent  all  danger  of  the  ligature 
slipping.  The  other  ligature  is  tied  around  the  ureter.  A  hemostatic  forceps 
is  applied  to  the  pedicle  between  the  ligatures  and  the  kidney.  The  pedicle 
is  divided  close  to  the  kidney,  leaving  the  hemostat  attached  to  the  stump. 
The  hemostat  gives  one  control  of  the  stump  and  is  left  in  position  until  the 
condition  of  the  stump  has  been  reviewed  and  it  is  evident  that  the  ligature 

*  The  writer  suspects  that  incision  into  these  peculiar  tumors  lets  loose  a  highly  toxic 
secretion  which  is  rapidly  absorbed  and  causes  great  acceleration  of  the  pulse-rate. 


NEPHRECTOMY.  539 

controls  the  vessels  and  is  in  no  danger  of  slipping.     After  this  the  forceps 
is  removed. 

Step  4. — Make  a  careful  and  complete  excision  of  the  fatty  capsule  of  the 
kidney.  This  is  as  important  as  e.xcision  of  the  axillary  glands  in  removal  of 
mammary  cancer.  The  excision  is  made  partly  by  blunt  dissection,  partly  by 
cutting  with  scissors.  All  firm  strands  of  tissue  in  which  vessels  may  be  hidden 
should  be  divided  between  ligatures  or  forceps.  There  must  be  no  rough  tear- 
ing.    The  location  of  the  inferior  vena  cave  should  be  borne  in  mind. 

Gregoire  thinks  that  the  suprarenal  body  ought  to  be  removed  with  the  kid- 
ney in  the  presence  of  renal  cancer. 

Step  5. — With  retractors  expose  to  sight  the  whole  retroperitoneal  cavity. 
All  hemorrhage  is  attended  to  and  any  tears  which  may  have  been  made  through 
the  peritoneum  are  closed  by  suture. 

Step  6. — Dry  the  cavity.  Provide  drainage  either  by  means  of  gauze  pack- 
ing or  by  tube.  Close  the  lumbar  wound.  Unless  the  wound  is  infected,  the 
drainage  may  be  dispensed  with  after  two  days. 

If  the  tumor  to  be  removed  is  very  large,  it  is  often  wise  to  seize  the  pedicle 
and  any  adhesions  with  forceps  and  attend  to  the  ligations  after  the  tumor  is 
out  of  the  way. 

Occasionally  thrombi,  malignant  in  character,  are  present  in  the  renal  vein 
and  even  in  the  inferior  vena  cava.  Such  thrombi  should  be  removed  even  if 
it  is  necessary  temporarily  to  clamp  the  vena  cava  itself.  Israel  is  authority 
for  this  advice. 

2.  Nephrectomy  for  non-malignant  disease:  If  the  kidney  is  not  too  adherent 
(as  a  result  of  old  inflammation)  to  its  surroundings,  the  whole  organ  can  be 
shelled  out  of  its  bed  by  finger  dissection.  A  pedicle  needle  is  passed  between 
the  vessels  and  the  ureter  as  they  enter  or  leave  the  hilus;  a  double  ligature  is 
pulled  through  as  the  needle  is  withdrawn.  One  ligature  is  tied  tightly  around 
the  vessels  as  already  described.  The  ligature  intended  for  the  ureter  is  not  yet 
tied.  The  ureter  is  grasped  by  forceps.  The  pedicle  is  divided,  leaving  a 
sufficiently  large  stump,  and  the  kidney  is  removed.  The  ureter  is  now  ex- 
amined. If  it  is  clean  and  safe,  the  ligature  provided  for  it  may  be  tied  and  the 
ureter  allowed  to  drop  into  the  wound.  If  the  ureter  is  infected  and  its  cavity 
dilated  and  full  of  pus,  it  must  be  thoroughly  cleansed  both  by  washing  and  by 
scraping  with  a  sharp  spoon.  After  being  cleaned,  the  ureter  may  be  ligated 
and  allowed  to  retract  into  the  wound,  or  it  may  be  left  open  and  fixed  to  the 
lumbar  wound  by  a  few  sutures.  If  the  disease  for  which  operation  is  performed 
be  tuberculous  and  the  ureter  is  involved,  it  may  be  followed,  through  the 
lumbar  wound,  down  to  the  brim  of  the  pelvis  and  excised  to  that  extent.  In 
any  event  an  effort  should  be  made  to  deprive  the  distal  ureter  of  its  mucous 
lining  and  to  close  the  upper  opening  of  the  distal  segment  by  inverting  it. 
Mayo  treats  the  ureter  by  injecting  into  it  about  a  drachm  of  liquid  carbolic 
acid.     He  finds  this  efifective  and  harmless. 

If  in  non-malignant  disease  the  kidney  is  so  firmly  adherent  to  its  surround- 


540  OPERATIONS    UPON    THE    KIDNEY. 

ings  as  to  make  removal  by  the  usual  method  a  matter  of  great  diflSculty,  then 
its  fibrous  capsule  may  be  opened  and  the  kidney  proper  separated  from  its 
capsule  and  removed,  leaving  the  fibrous  capsule  in  situ.  The  vessels  when 
isolated  are  caught  in  a  clamp  v^hich  is  left  in  situ.  If  the  organ  peels  out 
without  the  vessels  being  isolated  and  clamped,  pack  the  cavity  lightly  with 
gauze;  as  the  surrounding  scar  tissue  gives  ample  support  to  the  packing  this 
is  thoroughly  effective  for  purposes  of  hemostasis.  Any  diseased  material  ad- 
hering to  the  capsule  is  to  be  scraped  away. 

The  excision  of  a  very  large  hydronephrotic  kidney  calls  for  manoeuvres  not 
yet  considered.  Israel  says  that  observance  of  two  rules  makes  the  operation 
tolerably  easy  and  safe.  Firsl,  as  in  the  case  of  all  benign  tumors,  be  sure  to 
get  down  to  the  capsula  propria.  This  is  accomplished  by  cutting  the  tissues 
layer  by  layer,  each  layer  being  raised  by  two  forceps  before  being  cut  and  the 
cut  being  made  between  the  forceps.  It  is  surprising  how  many  layers  of  more 
or  less  firm  fibrous  tissue  are  formed  from  the  fatty  capsule  and  must  be  passed 
before  the  capsula  propria  is  reached.  Having  reached  the  capsule,  clear  as 
large  an  area  of  its  surface  as  is  possible  without  evacuating  its  contents. 
Second,  a  trocar  and  cannula  are  inserted  into  the  tumor  to  empty  it.  The 
cannula  is  provided  with  a  long  rubber  tube  to  drain  away  the  fluid  without 
soiling  the  wound.  When  the  tumor  has  collapsed,  withdraw  the  cannula,  at 
the  sajne  moment  closing  its  puncture  wound  by  catching  up  a  fold  of  the  tumor- 
wall  (at  the  point  of  puncture)  between  the  finger  and  thumb.  Forceps  may  be 
used  instead  of  the  digital  grasp.  Pull  the  now  flaccid  tumor-wall  out  of  the 
lumbar  wound,  separating  adhesions  with  the  flat  of  the  fingers  of  the  other 
hand  as  the  tumor  is  being  delivered.  Tough  adhesions  must  be  divided 
between  ligatures  or  forceps.  These  will  be  most  common  near  the  top  of  the 
tumor.  Do  not  bore  in  or  mine  with  the  fingers  around  the  tumor,  and  never 
endeavor  to  hook  out  the  growth  with  the  fingers.  Such  endeavors  may  tear 
the  pedicle  or  even  lacerate  the  vena  cava.  Everything  must  be  done  under 
control  of  the  eye.  When  the  sac  is  so  far  extracted  that  the  region  of  the  hilus 
is  reached,  even  more  care  must  be  exercised  in  the  separation  of  adhesions,  as 
in  hydronephrosis  the  veins  are  not  always  gathered  together  in  a  convenient 
pedicle,  but  are  spread  out  and  have  many  diverging  branches.  Operating 
in  the  above  manner,  every  vessel  may  be  seen  and  ligated. 

(B)  Nephrectomy  by  the  Abdominal  Route. — The  kidney  is  exposed  by 
Langenbuch's  incision  (page  516).  The  finger  passed  through  the  wound  in 
the  mesocolon  (page  516)  separates  the  kidney  from  its  surroundings  until  the 
hilus  is  reached.  With  an  aneurysm  needle  a  double  ligature  is  passed  be- 
tween the  ureter  and  the  vessels,  and  the  vessels  are  tied  in  two  places  and 
divided  between  the  ligatures.  This  double  ligation  is  practised  to  prevent  a 
flow  of  blood  from  the  kidney  which  would  obscure  the  wound.  The  ureter  is 
divided  between  forceps.  The  kidney  is  removed.  The  ureter  is  examined, 
and  if  found  clean  and  healthy,  it  is  ligated  and  allowed  to  retract  into  the  wound. 
The  whole  retroperitoneal  cavity  created  by  the  removal  of  the  tumor  is  examined 


REMARKS.  541 

and  any  bleeding  point  which  may  have  been  overlooked  receives  attention. 
Oozing  of  blood  is  lessened  by  temporary  pressure  with  gauze  pads  wrung  out 
of  hot  water.  Drainage  may  be  provided  through  the  lumbar  region  in  the 
following  manner:  From  the  cavity  to  be  drained  a  closed  forceps  is  thrust 
backwards  through  the  lumbar  tissues,  just  external  to  the  quadratus  lumborum 
muscle,  until  it  raises  the  skin  on  the  back.  The  skin  is  incised  and  the  point 
of  the  forceps  thrust  through  the  incision.  If  necessary,  the  opening  may  be 
enlarged.  Either  gauze  or  tubular  drains  may  be  employed,  according  to  cir- 
cumstances. The  above  operation  appears  easy  on  paper,  but  when  the 
kidney  is  much  enlarged  and  when  it  is  adherent  to  its  surroundings,  the  pro- 
cedure is  one  of  great  difficulty.  WTiile  the  organ  is  being  separated 
from  its  surroundings  it  may  be  necessary  to  apply  many  ligatures  to  control 
hemorrhage.  A  large  cystic  kidney  may  require  to  have  its  fluid  contents 
aspirated  before  the  pedicle  can  be  treated  or  the  tumor  delivered.  Of 
course,  under  such  circumstances  the  puncture  wound  made  by  the  aspirator 
or  cannula  must  be  closed  with  forceps  as  soon  as  the  instrument  is  withdrawn. 
Treatment  the  pedicle  often  presents  difficulties.  It  may  be  easier  to  apply 
clamps  to  the  vascular  pedicle  than  ligatures.  If  this  is  done,  much  care 
must  be  exercised.  Thornton  once  included  a  small  piece  of  the  vena  cava 
in  the  forceps  and  lost  his  patient  from  hemorrhage.  Hartmann,  while  enu- 
cleating a  large  pyonephrotic  kidney,  tore  a  hole  of  3  cm.  (i  1/4  inches) 
in  the  vena  cava,  below  the  renal  vein.  He  immediately  ligated  the  vena  cava 
above  and  below;  the  patient  recovered.  Had  the  tear  involved  the  region  of 
the  renal  veins,  he  would  have  sutured  the  wound  in  the  vena  cava.  Damar 
Harrison  has  done  this  successfully.  When  clamps  are  used,  ligatures  must  be 
substituted  for  them  as  soon  as  the  tumor  is  removed.  Some  surgeons,  when 
possible,  ligate  the  renal  vessels  before  enucleating  the  kidney.  When  the  ureter 
is  septic,  it  must  be  doubly  tied  near  the  kidney  and  divided  between  the  ligatures. 
The  ligation  prevents  its  septic  contents  escaping  into  the  wound.  The 
ureter  (after  the  kidney  is  removed)  is  pulled  outwards  and  fixed  in  the  lumbar 
drainage  wound.  Lumbar  drainage  having  been  provided,  the  abdominal 
wound  can  be  completely  closed.  Many  surgeons  advocate  careful  suture  of 
the  wound  made  through  the  outer  layer  of  the  mesocolon  so  as  to  close  the 
peritoneal  cavity.     This  is  generally  considered  unessential. 

Remarks. — Exploration  is  indicated  in  cases  where  it  is  believed  that  the 
kidney  has  been  ruptured  and  that  extravasation  of  urine  or  blood  is  taking 
place.  Any  lacerations  found  must  be  closed  by  suture.  If  mere  suturing  is 
insufficient  to  stop  the  hemorrhage,  or  if  the  trauma  has  destroyed  much  renal 
parenchyma,  the  wound  in  the  kidney  should  be  packed  with  gauze  held  in 
place  by  plain  catgut  sutures  (Fig.  631).  The  gauze  should  be  surrounded 
by  rubber  tissue  so  as  to  avoid  adhesion  between  it  and  the  kidney  tissues. 

The  happy  results  of  non-intervention  in  cases  of  uncomplicated  subcuta- 
neous rupture  of  the  kidney,  reported  by  Alfred  Frank  from  Korte's  clinic 
("Archiv  fiir  klin.  Chir.,"  Ixxxiii,  554),  are  such  as  to  dampen  operative  enthu- 


542  OPERATIONS    UPON    THE    KIDNEY. 

siasm.  Korte  never  operates  on  uncomplicated  cases  of  rupture  of  the  kidney, 
no  matter  the  extent  of  hemorrhage  and  hematoma.  If  infection  is  present 
operation  must  not  be  delayed. 

Ransohoff  promulgates  the  following  theses  regarding  renal  tuberculosis 
where  operation  in  indicated:  "  (i)  When  the  operation  reveals  a  strictly  localized 
lesion,  a  partial  excision  or  curettage  should  be  done.*  (2)  Nephrotomy  is 
indicated  when  uncertainty  exists  as  to  the  condition  of  the  opposite  kidney  or 
for  the  temporary  relief  of  an  acute  sepsis,  and  when  the  condition  of  the  patient 
will  not  permit  the  major  operation.  It  is  then  to  be  followed  as  speedily  as 
possible  by  nephrectomy.  (3)  Unless  unusual  conditions  call  for  nephrotomy, 
it  is  not  to  be  advocated  for  renal  tuberculosis.  It  may  even  do  harm  by 
autoinfection.  (4)  Primary  nephrectomy  should  be  considered  the  normal 
procedure  for  renal  tuberculosis  when  an  operation  is  at  all  indicated." 

Liechtenstern  ("German  Urological  Society,"  1907)  examined  at  intervals 
the  urine  of  seventeen  patients  submitted  to  nephrectomy  for  tuberculosis. 
The  examination  was  by  inoculation  of  guinea-pigs.  In  seven  the  results  were 
negative.  In  three  the  results  were  at  first  positive,  later  negative.  In  seven 
every  examination  showed  bacilli.  Voelker  reviewed  the  late  results  of  seven- 
teen cases  of  operation  for  renal  tuberculosis  in  the  Heidelberg  clinic  (1902  to 
1906).  His  conclusions  were  (a)  the  disease  is  less  grave  in  the  female;  (b) 
in  the  patients  who  sur\'ive  the  operation  the  symptoms  are  late  in  disappearing 
(up  to  two  years) ;  (c)  the  mortality  during  the  first  six  months  after  operation 
is  25  per  cent. 

The  presence  of  a  renal  calculus  always  calls  for  operation.  The  danger 
of  the  condition  and  especially  of  the  operation  is  not  so  much  due  directly 
to  the  stone  as  to  infection.  This  seems  a  truism,  but  in  renal  and  biliary  sur- 
gery physicians  and  patients- are  far  too  prone  to  delay  interference  until  such 
becomes  distinctly,  if  not  very,  dangerous.  The  same  reasons  which  make 
early  operation  safe  in  cases  of  appendicitis  call  for  early  operation  in  renal 
calculus,  although  in  the  latter  a  moderate  amount  of  delay  does  not  lead  to 
such  disastrous  results. 

Pyonephrosis  or  surgical  kidney  demands  operation.  If  the  disease  is 
so  severe  that  drainage  will  put  too  great  strain  on  the  patient's  recuperative 
powers;  if  the  other  kidney  is  in  such  health  that  it  can  be  depended  upon  for 
elimination,  and  if  the  immediate  condition  of  the  patient  permits  nephrectomy, 
then  nephrectomy  is  the  operation  of  choice.  When  doubt  exists  as  to  the 
functional  ability  of  the  other  kidney,  or  when  the  general  condition  of  the 
patient  contraindicates  the  more  severe  operation,  drainage  is  the  operation 
of  choice.  The  same  is  true  in  calculus  disease  when  infection  is  present. 
If  in  the  above  disease  the  inflammatory  process  is  moderate  and  a  useful 
amount   of   renal   parenchyma   remains   iiitact,    drainage   gives   excellent   re- 

*  The  author  has  mistaken  an  apparently  well-encapsulated  hypernephroma  for  a  local-' 
ized  tuberculous  lesion,  performed  partial  excision,  and  obtained  a  disastrous  result.  This 
error  is  easily  made,  and  should  be  remembered. 


REMARKS.  543 

suits,  or  partial  nephrectomy  plus  drainage  may  be  the  better  procedure  to 
adopt. 

Anuria,  especially  calculus  anuria,  calls  for  nephrotomy,  and,  as  Morris 
points  out,  the  operation  ought  to  be  on  the  kidney  which  appears  to  have 
become  last  affected,  i.  e.,  on  the  organ  which  presumably  is  in  the  better  con- 
dition. Anuria  following  nephrectomy  calls  for  immediate  nephrotomy  on 
the  remaining  kidney.     (Willy  Meyer.) 

Harrison  demonstrated  long  ago  that  operations  undertaken  for  calculi 
proved  in  many  instances  curative,  even  when  no  calculi  were  found,  and  he 
concluded  that  nephrotomy  might  be  a  reliable  therapeutic  agent  in  certain 
cases  of  acute  nephritis  by  relieving  renal  tension.  A.  H.  Ferguson,  Edebohls, 
and  others  believe  that  by  decortication  of  the  kidney  a  cure  (symptomatic 
at  least)  may  be  obtained  in  chronic  interstitial  nephritis.  At  present  this 
subject  is  distinctly  sub  judice,  but  very  remarkable  results  have  been  claimed 
by  thoroughly  reliable  men. 

E.  Martini  ("  Archiv  fur  klin.  Chir.,"  Ixxviii,  p.  619)  experimented  on  dogs. 
At  various  periods  after  kidney  decortication  (even  after  many  months)  he 
killed  the  animals  by  bleeding;  ligated  the  renal  artery  and  vein  and  then  in- 
jected colored  gelatin  through  the  aorta  and  ascending  vena  cava.  By  these 
means  Martini  was  able  to  study  the  collateral  circulation  of  the  kidney.  An 
abstract  of  his  conclusions  follows: 

1.  The  new  renal  capsule  is  principally  the  result  of  growth  of  the  inter- 
stitial connective  tissue  and  of  the  endothelium  of  the  vessels  of  the  cortical 
zone  of  the  cortex. 

2.  New  capsule  is  firmly  adherent  to  the  kidney,  is  not  of  uniform  thickness, 
but  is  thicker  than  the  normal  capsule.  Its  thickness  is  greater  if  the  fatty 
capsule  has  been  removed  and  nephropexy  performed  as  well  as  decortication. 

3.  The  new  capsule  shows  no  tendency  to  shrink  or  to  sclerosis;  it  retains 
its  normal  structure  and  rich  vascularity. 

4.  Decapsulation  causes  only  temporary  phenomena  of  hyperemia  in  the 
periphery  of  the  kidney  and  no  epithelial  degeneration. 

5.  There  is  a  temporary  decrease  in  the  secretion  of  urine  from  simple 
causes. 

6.  Ligation  of  the  renal  artery  or  vein  causes  more  degeneration  and 
necrosis  in  normal  than  in  previously  decapsulated  kidneys. 

7.  The  collateral  circulation  through  the  new  capsule  can  fully  compen- 
sate for  the  stoppage  of  outflow  through  the  renal  vein  when  it  is  ligated;  it 
only  partially  takes  the  place  of  the  renal  artery  when  that  is  ligated. 

8.  Decapsulation  and  simultaneous  ligation  of  the  corresponding  renal 
vein  is  fatal. 

9.  If  both  kidneys  have  been  decapsulated  and  are  provided  with  a  new- 
formed  capsule,  one  renal  vein  may  be  ligated  and  a  month  later  the  other 
ligated  also  without  death  of  the  animal. 

10.  A  dog  can  survive  simultaneous  ligation  of  the  artery  and  vein  of  one 


544  OPERATIONS    UPON   THE   KIDNEY. 

kidney  only  when  the  fibrous  capsule  of  that  kidney  has  been  previously  ex- 
tirpated. 

II.  The  collateral  circulation  of  a  previously  decapsulated  kidney  is 
sufficient  to  preserve  the  life  of  a  dog  when  the  other  kidney  is  removed  and 
the  vein  of  the  decapsulated  kidney  is  ligated. 

Horse-shoe  Kidney.— A.  Martinow  ("Zentralblatt  fur  Chir.,"  1910,  No.  9) 
describes  a  case  of  horse-shoe  kidney  in  which  he  operated  vnth  good  effect. 
The  report  is  so  suggestive  that  it  requires  consideration  and  may  aid  the 
surgeon  in  locating  a  very  limited  class  of  obscure  abdominal  trouble.  A 
nurse,  aged  forty-nine,  complained  from  child-hood  of  a  disagreeable  pulsating 
sensation  in  the  whole  abdomen;  for  many  years  there  was  severe  pain  above 
the  umbilicus  and  marked  obstipation.  The  pains  increased  and  did  not 
disappear  at  night.  The  patient  became  hysterical,  and  underwent  treat- 
ment for  hysteria  during  many  years.  Appetite  poor;  occasional  vomiting; 
bowels  moved  every  two  or  three  days;  marked  peristalsis  and  abdominal 
pains.  A  tumor  was  palpable  above  the  umbilicus.  Aorta,  tumor,  and 
cjecum  tender  on  pressure.  Tumor  occasionally  increases  in  size  when  the 
pulsation  of  the  aorta  and  other  abdominal  arteries  becomes  stronger  and 
more  annoying.     No  pain  in  the  kidney  regions.     All  other  organs  normal. 

Diagnosis — Tumor  pancreas  or  horse-shoe  kidney.  Laparotomy  was  per- 
formed. A  tumor  was  found  lying  directly  on  the  aorta;  it  was  about  4  cm. 
wide  and  2  cm.  thick  and  formed  an  isthmus  uniting  the  two  kidneys  lying 
one  on  each  side  of  the  vertebral  column.  The  diagnosis  of  horse-shoe  kidney 
was  clear.     Each  half  of  the  abnormal  kidney  was  provided  with  a  ureter. 

After  incision  of  the  peritoneum  overlying  the  tumor  the  isthmus  was 
grasped  with  two  intestinal  clamps  and  divided.  Immediately  the  two  halves  of 
the  kidney  retracted  one  from  the  other  and  the  aorta  was  freed  from  pressure. 
After  removal  of  the  clamps  from  the  kidney  hemorrhage  was  easily  controlled 
by  a  few  catgut  sutures.  The  peritoneal  wound  was  sutured  and  the  abdo- 
men closed  without  drainage.  Martinow  writes  "I  would  not  assert  that  the 
isthmus  should  be  divided  in  cases  where  horse-shoe  kidney  is  discovered 
accidentally  during  an  operation,  but  I  do  intimate  that  in  cases  with  symptoms 
due  to  pressure  on  the  sympathetic  plexus  this  simple  operation  is  possible 
and  ought  to  be  tried." 


CHAPTER  XLV. 
OPERATIONS  ON  THE  URETER.* 

Anatomy. — The  ureters  conduct  the  urine  from  the  kidneys  to  the  base 
of  the  bladder,  the  walls  of  which  they  pierce  obliquely,  thus  providing  them- 
selves with  valvular  outlets.  The  average  length  of  the  ureter  is  12  inches; 
its  narrowest  point  is  about  21/2  inches  below  the  hilum  of  the  kidney  (diameter 
here  about  1/8  inch),  and  the  next  narrowest  point  is  at  the  brim  of  the  pelvis. 
Calculi  are  liable  to  become  caught  at  these  two  places  and  at  the  point  where 
the  bladder  is  entered.  The  ureters  are  lined  by  a  thin  mucosa  which  is 
thrown  into  folds.  A  thick  muscular  and  a  thin  but  elastic  external  fibrous 
tunic  completes  the  ureteral  wall. 

The  ureter  lies  loosely  in  the  post-peritoneal  connective  tissue.  "In  the 
abdominal  portion  of  its  extent  it  lies  upon  the  front  of  the  psoas  muscle,  and 
about  half-way  between  its  commencement  and  the  brim  of  the  pelvis,  or  some- 
where below  that  point,  it  crosses  in  front  of  the  genito-crural  nerve.  The 
upper  half  of  this  portion  of  the  duct,  except  at  its  commencement  on  the  right 
side,  where  it  is  covered  by  a  third  part  of  the  duodenum,  is  in  direct  contact 
with  the  peritoneum,  to  which  it  is  intimately  connected;  and  the  lower  half 
is  separated  from  the  peritoneum  by  the  spermatic  or  ovarian  vessels,  which 
are,  however,.closely  united  boLh  to  the  ureter  and  to  the  serous  membrane.  .  . 
At  the  brim  of  the  pelvis  the  relation  of  the  ureter  to  the  large  vessels  is  not 
always  quite  the  same,  as  it  may  rest  either  upon  the  lower  end  of  the  common 
iliac  artery  or  upon  the  external  iliac;  it  is  covered  in  front  by  the  peritoneum 
and  it  is  crossed  on  the  right  side  by  the  termination  of  the  ileum,  and  on  the 
left  by  the  commencement  of  the  rectum."  (Morris,  "Surgery  of  the  Kidney 
and  Ureter.") 

Tourneur's  point  corresponds  approximately  to  the  upper  end  of  the  ureter 
and  the  level  of  origin  of  the  spermatic  or  ovarian  artery.  Draw  a  transverse 
line  from  the  tip  of  one  twelfth  rib  to  that  of  the  other.  Draw  a  vertical  line 
upwards  from  the  junction  of  the  middle  and  inner  thirds  of  Poupart's  liga- 
ment.    Where  these  two  lines  cross  is  Tourneur's  point. 

To  find  where  the  ureter  crosses  the  iliac  artery,  Morris  gives  the  following 

advice:     For  practical  purposes,  a  point  lying  at  the  junction  of  the  upper  and 

•middle  thirds  of  the  line  indicating  the  course  of  the  common  and  external 

iliac   arteries  will   sufficiently   indicate  its   position.     The  line   marking   the 

course  of  the  iliac  vessels  is  drawn  from  the  bifurcation  of  the  aorta,  half  an 

*  In  this  chapter  very  free  use  has  been  made  of  Morris'  work  on  "Surgical  Diseases  of 
the  Ureter  and  Kidney." 

35  545 


546 


OPERATIONS    ON   THE    URETER, 


inch  below  and  to  the  left  of  the  umbilicus,  to  midway  between  the  anterior 
superior  spine  of  the  ilium  and  the  symphysis  pubis. 

Hydronephrosis  is  commonly  the  result  of  ureteral  obstruction,  whether 
due  to  calculus,  stricture,  external  pressure,  or  torsion  of  the  tube  from  renal 
ptosis.     Of  course,  the  cause  must  be  sought  and,  if  possible,  removed. 


(Eckehorn.) 


Fig.  636. — {Eckehorn.) 


Very  frequently  a  branch  from  the  renal  artery,  or  even  direct  from  the  aorta 
enters  the  kidney  at  a  point  remote  from  the  pelvis.  The  ureter  may  become 
kinked  over  this  branch.  The  above  is  a  common  cause  of  hydronephrosis 
and  ligation,  and  division  of  the  aberrant  vessel  is  usually  the  proper  treatment. 


Fig.  637. — (Eckehorn.) 


{Bazy.) 


A  glance  at  Figs.  635,  636  and  637  shows  diagrammatically  the  relations 
of  the  ureter  to  aberrant  vessels,  while  Figs.  638,  639  and  643  show  how  the 
vessels  may  produce  hydronephrosis. 

Bland  Sutton  believes  that  the  kinking  of  the  ureter  over  the  abdominal 
vessel  is  the  result,  not  the  cause  of  the  hydronephrosis.     A  number  of  reli- 


HYDRONEPHROSIS. 


547 


able  surgeons,  however,  find  that  the  hydronephrosis  is  cured  after  division 
of  the  vessel  apparently  causing  the  kinking. 

It  is  important  to  note  the  relationship  between  the  ureter  and  the  pelvis 
of  the  kidney.  Normally  the  ureter  opens  into  the  lowest  point  in  the  pelvis, 
but  in  hydronephrosis  the  opening  may  be  high  up  on  the  pelvic  wall,,  and 
hence  escape  of  fluid  from  the  kidney  becomes  impossible  even  if  the  original 
obstruction  of  the  ureter  is  remedied.  Various  operations  have  been  devised 
for  the  correction  of  the  faulty  relation  between  ureter  and  renal  pelvis. 

Mynter's  Method. — Expose  and  explore  the  kidney  and  its  pelvis.  Make 
an  incision  into  and  explore  the  interior  of  the  greatly  dilated  pelvis  or  the 
hydronephrotic  sac.  If  possible,  pass  a  catheter  through  the  ureter  down 
to  the  bladder  and  find  if  ureteral  stenosis  exists.     If  the  opening  of  the  ureter 


Fig.  639. — {Bazy.) 


Fig.  640. 


is  high  up  on  the  side  of  the  sac  (Fig.  640),  make  the  incision  A,  B,  through 
the  wall  of  the  sac,  parallel  and  opposite  to  the  ureter.  Make  the  similar 
incision  A,  C,  in  the  ureter.  Unite  the  anterior  edge  of  the  ureteral  wound 
to  the  anterior  edge  of  the  sac  wound  (x-x^,  Fig.  641).  Unite  the  posterior 
edge  of  the  ureteral  wound  to  the  corresponding  edge  of  the  sac  wound 
(y-y^).  The  sutures,  of  fine  silk  or  hemp,  must  not  include  the  mucosa  in 
their  bite.  (This  lest  calculi  form  on  them.)  The  result  is  a  lowering  of  the 
ureteral  orifice  to  the  lowest  point  in  the  sac.  The  operation  is  identical  in 
principle  with  Mikulicz's  pyloroplasty.  If  a  ureteral  stricture  exists  be- 
tween the  points  A  and  C,  the  operation  of  course  cures  that  also.  When  ob- 
struction is  due  to  kinking  of  the  ureter  over  one  of  the  renal  vessels,  either 
make  an  anastomosis  between  the  sac  and  the  ureter  below  the  obstruction 
(Fig.  643,  x-y)  or  divide  the  ureter  and  unite  the  open  end  of  the  lower  seg- 
ment to  the  lowest  point  in  the  hydronephrotic  sac. 

Mayo's  method  of  using  a  flap  of  fat  to  support  the  line  of  suture  in  the 
kidney  pelvis  is  most  valuable  (see  p.  536). 

Kiister  ("Archiv  f.  klin.  Chir.,"  xliv,  850)  describes  a  case  where  the  above 
operations  were  impracticable,   as  an  impermeable  stricture  of  the  ureter 


548 


OPERATIONS    ON    THE    URETER. 


existed  a  short  distance  below  the  sac.  He  divided  the  ureter  immediately 
below  the  stricture,  separated  it  sufficiently  from  its  surroundings  so  that  it 
could  be  brought  up  to  the  sac  without  tension,  split  the  upper  end  of  the  ureter 
(Fig.  644),  made  an  incision  through  the  posterior  wall  of  the  sac  at  his  lowest 
level,  spread  open  the  split  upper  end  of  the  ureter  and  sutured  it  to  the  vivi- 


Renal 
VessEUS 


Fig.  641. 


Fig.  642. 


Fig.  643. — {Modified 
from  Morris.) 


fied  internal  surface  of  the  anterior  wall  of  the  sac  (Fig.  645).  The  ureter 
was  thus  formed  into  a  sort  of  funnel  opening  into  the  sac.  The  wound  in 
the  sac  was  closed  with  sutures  (Fig.  646).  The  result  was  good.  Israel 
has  lessened  the  size  of  the  distended  pelvis  by  a  plication  of  its  walls  similar 
to  that  practised  for  the  cure  of  dilatation  of  the  stomach.  Occasionally  in 
hydronephrosis  a  valve  is  present  at  the  ureteroplevic  junction,  which  prevents 
the  complete  evacuation  of  the  renal  pelvis  or  hydronephrotic  sac.     Fenger's 


m 


Fig.  644. 


Fig.  645. 


operation  for  this  condition  is  as  follows:  Expose  the  kidney.  Open  the 
renal  pelvis  and  examine  the  interior,  especially  the  ureteral  opening.  Pass 
a  bougie  into  the  ureter.  Excise  the  valve  by  a  transverse  incision  (Fig.  647, 
A  B).  Close  with  fine  catgut  sutures  the  wound  left  by  the  incision  of  the 
valve.     Close  the  wound  in  the  sac. 


EXPOSURE    OF    URETER. 


549 


When  hydronephrosis  is  due  to  or  kept  up  by  a  stricture  at  the  junction 
of  the  ureter  and  pelvis,  the  operation  practised  by  Fenger  was  the  following: 
Make  the  incision  A,  a  (Fig.  648),  through  the  stricture  and  continue  for  a  short 
distance  upwards  through  the  sac- wall  and  downwards  through  the  ureteral  wall. 
With  sutures  unite  the  points  A,  a;  B,  b;  C,  c,  etc.  This  practically  amounts 
to  an  anastomosis  between  the  ureter  and  the  renal  pelvis.  To  avoid  tension 
it  may  be  necessary  to  separate  the  ureter  from  its  surroundings  for  a  short 
distance. 

Exposure  of  the  Ureter. — (A)  Transperitoneal  Route. — The  ureter  can 
be  reached  through  a  median  or  lateral  abdominal  incision.  This  method 
is  valuable  as  a  means  of  diagnosis,  permitting,  as  it  does,  palpation  of  the 
opposite  kidney,  and  the  recognition  of  stones  impacted  in  the  ureter  and  of 
other  conditions.  When  a  stone  is  situated  low  down  in  the  ureter  it  may 
be  palpated  through  an  incision  through  the  rectus  muscle  or  through  a  "grid- 


Ufete^ 


Fig.  647. 


iron  incisien  such  as  used  in  appendectomy,  but  placed  a  little  more  ex- 
ternal than  in  the  latter  operation.  Guided  by  a  finger  in  the  abdomen, 
strip  the  peritoneum  from  the  parietes  on  the  outer  side  of  the  wound  until  the 
ureter  and  stone  are  exposed.  Protect  the  wound  in  the  peritoneum  either 
by  packing  or  by  closing  it.  Incise  the  ureter  extraperitoneally.  Provide 
drainage  through  a  separate  incision.  Morison  has  frequently  operated  in 
this  fashion  and  has  never  infected  the  peritoneum.  John  Gibbon  has  had 
similar  experience.  In  operations,  such  as  uretero-ureterostomy  and  uretero- 
cystostomy,  etc.,  the  transperitoneal  route  is  of  great  value. 

(B)  Extraperitoneal  Routes. — I.  Lumho-ilio-inguiiial  route  (Morris):  By 
this  route  the  ureter  may  be  explored  throughout  its  whole  length,  {a)  Ex- 
ploration of  lumbar  portion  of  ureter.  Place  the  patient  lying  on  his  healthy 
side  with  the  abdomen  turned  somewhat  towards  the  table.  Do  not  place 
any  pillow  under  the  opposite  loin.  Beginning  at  the  outer  edge  of  the 
sacro-lumbar  mass  of  muscles,  a  little  below  the  twelfth  rib,  make  an  inci- 
sion obliquely  forwards  and  downwards  to  a  point  i  inch  internal  to  the  ante- 
rior superior  spine  of  the  ilium.  Continue  the  incision  parallel  to  and  i  inch 
above   Poupart's   ligament,   as    far  as  its  centre   (Figs.   649  and  650).     Cut 


550 


OPERATIONS    ON    THE    URETER. 


down  to,  but  not  through,  the  peritoneum.  Expose  the  kidney.  Palpate  the 
renal  pelvis  between  finger  and  thumb.  By  exercising  slight  traction  on  the 
pelvis  the  ureter  may  be  made  more  prominent.  With  the  fingers  or  a  pledget 
of  gauze  strip  the  peritoneum  from  the  parietes  until  the  ureter  is  seen.  "The 
relation  of  the  ureter  to  that  part  of  the  peritoneum  which  is  adherent  to  the 
spine  is  rather  constant,  the  ureter  being  situated  just  external  to  the  line  of 
adhesion.  Therefore,  when  the  operator  has  stripped  up  the  peritoneum  and 
reached  this  point,  he  will  find  the  ureter  on  the  stripped-up  peritoneum  ex- 
ternal to  it."  (Kelly.)  Remember  that  the  ureter  adheres  to  the  peritoneum 
even  when  that  membrane  is  raised  from  the  subjacent  structures.  A  little 
tension  exercised  on  the  renal  pelvis  helps  to  render  the  ureter  recognizable. 
(6)  Exploration  of  pelvic  portion  of  ureter.  Roll  the  patient  over  so  that 
while  still  resting  on  his  sound  side  his  back,  instead  of  his  abdomen,  is  turned 


Fig.  649.  Fig.  650. 

Figs.   549  and  550. — {Munod  and  Vanverts.) 


somewhat  towards  the  table.  Enlarge  the  wound,  if  necessary,  forwards,  "even 
as  far  as  the  external  abdominal  ring"  (Morris),  always  carefully  avoiding  open- 
ing the  peritoneum.  This  huge  wound  may  be  avoided  by  seeking  the  pelvic 
ureter  through  a  low  "gridiron"  incision  which  penetrates  to,  but  not  through, 
the  peritoneum.  Should  the  peritoneum  be  opened  by  accident,  close  it  at 
once  with  sutures.  Sometimes  the  kidney  is  not  available  as  a  guide  to  the 
ureter  and  one  is  forced  to  hunt  for  that  tube  at  the  pelvic  brim.  Here  the 
guide  to  the  ureter  is  the  place  where  it  crosses  the  iliac  artery,  and  when  the 
peritoneum  is  stripped  off,  it  will  be  found  adhering  to  that  membrane  "like 
a  whitish  or  yellowish-white  tape."  In  the  male  the  ureter  may  be  examined 
in  this  manner  down  to  the  bladder,  but  in  the  female  it  runs  in  the  broad 
ligament,  which  makes  it  very  difficult  of  access.  The  uterine  artery  lies  in 
front,  the  veins  behind,  the  ureter. 

II.  TJie  sacral  route:  Morris  thus  describes  Delbet's  operation:  "(i) 
The  patient  should  be  placed  upon  his  sound  side,  so  that  the  rectum  may  fall 
away  from  the  wound.  (2)  The  incision  should  be  L-shaped,  with  the  long 
arm  vertical,  along  the  border  of  the  coccyx,  and  the  short  falling  upon  the 


URETEROTOMY. 


5^1 


superior  extremity  of  the  tirst,  being  almost  parallel  to  the  fibres  of  the  gluteus 
maximus.  (3)  Cut  the  insertion  of  this  muscle  and  the  sacro-sciatic  ligaments 
and  some  fibres  of  the  pyriformis.  (4)  Lay  bare  the  lateral  face  of  the  rectum 
with  forceps  and  a  director.  The  ureter  is  always  to  be  found  adherent  to 
the  detached  peritonev^m,  and  can  be  followed  downwards  to  the  bladder  and 
upwards  for  seven  or  eight  cm.  from  its  termination.  This  description  applies 
specially  to  man;  in  woman  the  operation  is  more  difficult  because  of  the 
broad  ligament." 

Various  surgeons  have  used  modifications  of  Kraske's  sacral  operation 
to  gain  access  to  the  ureter,  but  these  have  little  to  recommend  them. 

(C)  Perineal  Route. — An  operation  through  the  perineum,  very  similar  to 
that  used  for  the  exposure  of  the  prostate  by  a  curved  transverse  incision, 
permits  the  exposure  of  the  seminal  vesicles,  and  with  them  the  lower  end  of 
the  ureter. 

(D,  E)  Vaginal  and  Rectal  Routes. — Ureteral  calculi  palpated  through  the 
vagina  or  rectum  have  been  successfully  removed  by  direct  incision  through 
the  walls  of  these  cavities.     The  wounds  were  sutured  immediately. 


Fig.  651. 


Fig.  6^2. 


(F)  Transzesical  Route. — Calculi  impacted  at  the  vesical  orifice  of  the  ureter 
may  be  reached  and  removed  by  suprapubic  or  perineal  cystotomy.  Young 
and  Bransford  Lewis  have  successfully  removed  calculi  in  this  position  by 
means  of  the  cystoscope. 

Ureterotomy  and  Uretero-lithotomy. — Expose  the  ureter  by  one  of 
the  extraperitoneal  methods.  Introduce  into  it,  if  possible,  two  catgut  sutures 
(x-x',  Y-Y^  Fig.  651),  each  of  which  is  in  the  long  axis  of  the  ureter.  Using 
the  sutures  to  fix  the  tubes,  make  a  longitudinal  incision  into  the  ureter,  over 
the  calculus,  if  such  is  present.  It  is  wise,  when  possible,  to  push  the  stone 
up  the  ureter,  incising  at  this  new  point  lest  ulceration  at  the  site  of  impaction 
interfere  with  healing.  Remove  the  calculus  or  explore  the  ureter  as  may  be 
indicated.  Apply  a  long  strip  of  folded  rubber  tissue  or  oil-silk  over  the 
ureteral  wound  between  the  two  sutures.  Tie  the  end  of  the  suture  x  over 
the  rubber  tissue  to  Y,  and  the  end  of  the  suture  x\  similarly  to  Y^  (Fig.  6-52). 


552 


OPERATIONS    ON    THE    URETER. 


Bring  the  free  end  of  the  rubber  tissue  or  oil-silk  out  of  the  wound  in  the  parietes. 

Close  the  parietal  wound  except  where  the  drain  emerges.     This  closes  the 

ureteral  wound  efl&ciently  and  safely. 

Many  surgeons  suture  the  wound  in  the  ureter  with  a  few  fine  silk  or  hemp 

stitches  which  do  not  involve  the  mucosa;  other  surgeons  omit  all  suture  of  the 
ureteral  wound,  trusting  to  nature  to  close  the  wound, 
draining  the  wound  with  rubber  tissue  or  tube.  Simple 
through-and-through  sutures  of  catgut  are  all  that  is 
necessary,  but  a  drain  of  rubber  tissue  or  oil-silk  ought 
always  to  be  attached  to  the  line  of  suture.  The  use 
of  gauze  in  connection  with  renal  or  ureteral  wounds  is 
liable  to  lead  to  the  formation  of  fistulae.  Wlien  drain- 
age of  the  ureter  is  desired,  one  may  act  as  follows: 

Trim,  in  the  fish-tail  fashion,  the  end  of  an  appro- 
priate sized  rubber  tube;  wrap  around  the  tube  a  few 
layers  of  gauze;  cover  the  gauze  with  rubber  tissue. 
Leave  about  1/4  inch  of  the  "fish-tail"  end  of  the  tube 
free  from  gauze.  Perform  the  ureterotomy,  using  catgut 
sutures  as  handles  (Fig.  653).  Introduce  the  bared  end 
of  the  dressed  tube  into,  or  over,  the  ureter.  Do  not 
permit  the  gauze  on  the  tube  to  be  in  contact  with  the 

ureter.      With  a  needle  stitch  sutures  x-x^  and  y-y^  to  the  tube;  this  holds 

the  drain  in  place. 

Ureterotomy  for  the  cure  of  ureteral  stricture  is  performed  as  follows 

(Fenger's  operation): 

Expose  the  ureter  by  the  extraperitoneal  route.     Make  a  longitudinal  in- 
cision into  the  ureter  immediately  above  the  stricture;  pass  a  suitable  probe 


Fig.  65^ 


Fig.  656. 

or  bougie  through  the  stricture;  continue  the  vertical  incision  through  the 
stricture  and  downwards  until  the  wound  below  the  site  of  stricture  is  equal 
in  length  to  that  above  (Fig.  654).  With  sutures  unite  the  point  a  to  a\  b  to  bS 
etc.  (Fig.  655).  The  result  is  practically  the  formation  of  an  anastomosis 
(Fig.  656)  between  the  upper  and  lower  segments  of  the  tube.  Close  the 
external  wound  after  providing  for  drainage. 


URETERECTOMY. 


55: 


Ureterectomy. — Ureterectomy  may  be  carried  out  as  a  step  in  the  opera- 
tion of  nephrectomy  or  as  a  secondary  operation.  The  ureter  is  exposed  ex- 
traperitoneally  by  the  lumbo-ilio-inguinal  incision.  It  is  not  always  necessary 
to  make  the  external  incision  continuous  throughout  the  whole  length  described 
on  page  549.  After  the  kidney  is  delivered  or  removed  the  ureter  may  be 
followed,  by  a  burrowing  dissection,  down  towards  the  pelvis,  a  forceps  or 


Fig.  657.  Fig.  658. 

stout  probe  passed  down  to  the  bottom  of  the  wound  to  act  as  a  guide,  while 
a  second  incision  is  made  through  the  parietes  (Fig.  657).  No  special  de- 
scription of  technic  is  required.  Note  that  an  apparently  tuberculous  ul- 
ceration of  the  vesical  muscosa  near  the  mouth  of  the  ureter  is  not  a  contrain- 
dication to  nephrectomy  and  ureterectomy.  WTien  the  diseased  kidney  and 
ureter   are   removed,    the   vesical   lesion   frequently   recovers   spontaneously. 

Ureteral  Anastomosis. — (A)  MonarVs  MetJiod:  Lateral 
Anastomosis.— This  operation  is  practically  the  same  as  lateral 
anastomosis  of  the  intestine.  Fig.  658  sufl&ciently  explains  the 
method,  which  is  in  every  way  inferior  to  the  Van  Hook  operation. 

(B)  Van  Hookas  Operation:  Lateral  Implantation. — Split  the 
upper  segment  of  ureter  for  a  short  distance.  This  is  important, 
as  it  prevents  stenosis  at  the  onfice  (Fig.  659).  Ligate  the  upper 
end  of  the  lower  segment  of  ureter.  Pass  the  fine  catgut  suture 
X  Y  through  the  lower  wall  of  the  upper  segment  opposite  the 
split  described  above  (Fig.  659).  Make  a  vertical  incision  into 
the  lower  segment  immediately  below  the  site  of  ligation.  With 
round  needles  (either  straight  or  curved)  pass  the  suture  x  Y  through  the  open- 
ing in  the  ureter  and  make  its  ends  emerge  at  the  points  o.  n.  (Fig.  660).  As 
catgut  is  not  easily  threaded  in  fine  needles,  one  may  arm  the  needles  with  a 
suture  carrier  of  silk  or  hemp,  by  which  means  the  introduction  of  the  catgut 
becomes  easy  (Fig.  661).  Insert  the  lower  end  of  the  upper  segment  of  ureter 
through  the  wound  in  the  lower  segment,  pull  the  suture  x  y  sufficiently  tight, 
and  tie  it  (Fig.  662). 


Fig.  659. 


554 


OPERATIONS    ON    THE    URETER. 


Fig.  66b. 


[i  ff  Whenever  possible,    the   extraperitoneal   route   should  he 
chosen  in  performing  uretero-ureterostomy . 

Uretero-cystostomy. — This  operation  is  called  for  in 
certain  cases  of  persistent  ureteral  fistula,  in  cases  where 
part  of  the  ureter  has  been  destroyed  in  the  course  of 
operations,  e.  g.,  on  the  uterus.  It  takes  the  place  of 
removal  of  the  corresponding  kidney,  and  where  feasible 
is  the  operation  of  choice. 

(A)  Vaginal  Route. — Wlien  done  to  cure  a  uretero- 
vaginal  fistula,  the  operation  consists  essentially  in  freeing 
the  lower  end  of  the  ureter  from  its  surroundings  and  in 
suturing  it  into  a  small  opening  in  the  bladder.  When 
freeing  the  ureter,  a  bougie  or  probe  passed  into  it  is  a 
most  valuable  aid.  The  method  of  uniting  the  duct  to 
the  bladder  will  be  described  in  the  succeeding  pages. 

(B)  Superior  Extraperitoneal  Route. — Expose  the  ureter 
by  the  lumboilio-inguinal  incision  or  a  modification  thereof. 

This  is  much  less  difficult  to  accomplish  in  the 
male  than  in  the  female,  so  far  as  the  pelvic  seg- 
ment of  the  ureter  is  concerned;  the  broad  liga- 
ment interferes  considerably  in  the  female. 

(C)  Transperitoneal  Route  with  Extraperitoneal 
Uretero-cystostomy  (Witzel's  operation). — Open 
the  abdomen  by  a  median  incision  in  the  hypo- 
gastrium.  Incise  the  peritoneum  over  the  iliac 
vessels,  separate  the  peritoneum  from  the  sub- 
jacent structures  by  blunt  dissection.  The  ureter 
will    be    found    united    to    the   peritoneum   and 

elevated  with  it.  Make  slight  upward  traction  on  the  ureter 
to  make  it  prominent  and  recognizable  low  down,  in  the  broad 
ligament.  By  a  second  incision  in  the  broad  ligament  expose 
the  ureter;  divide  it;  ligate  and  cauterize  the  opening  in  the 
lower  segment.  Pull  the  upper  segment  up  to  and  out  of  the 
original  incision  over  the  iliac  vessels.  With  a  long  forceps 
guided  behind  the  peritoneum  to  the  side  of  the  vesical 
region  "above  the  linea  innominata,"  through  this  tunnel 
under  the  peritoneum,  draw  the  ureter  down,  and  anastomose 
it  to  the  bladder  extraperitoneally.  Close  the  two  small 
wounds  in  the  peritoneum.  To  make  the  anastomosis  with- 
out tension  on  the  line  of  suture  Witzel  pulled  the  bladder 
towards  the  ureter  and  fixed  it  there,  to  the  posterior  parietes 
at  the  line  of  the  peritoneal  incision. 

(D)  Intraperitoneal  Route. — This  method  has  been  used 
Fig.  662.  successfully  in  a  number  of  cases  and  seems  to  be  the  method 


'fiiteNeedlt 


Fig.  661. 


URETERO-CYSTOSTOMY.  555 

of  choice  when  uretero-cystostomy  is  undertaken  in  the  course  of  an  abdominal 
operation  in  which  the  ureter  has  been  divided.  The  end  of  the  upper  seg- 
ment of  the  ureter  must  be  found,  if  necessary  in  the  manner  described  in 
Witzel's  operation,  and  sufficient  of  it  separated  from  its  surroundings  to 
permit  its  approximation  to  the  bladder,  without  tension.  To  aid  in  this 
approximation  Witzel's  plan  of  suturing  the  bladder  to  the  side  of  the  pelvis 
may  be  useful,  but  Kelly's  procedure  is  better.  Kelly  detaches  the  bladder 
from  the  horizontal  rami  of  the  pubes  and  thus  can  bring  the  bladder  to  the 
ureter.  The  dissection  of  the  ureter  ought  not  to  be  too  "clean"  lest  nutrition 
be  threatened  and  necrosis  result. 

Methods  of  Uniting  the  Ureter  to  the  Bladder. — (A)  Pass  a  forceps 
through  the  urethra  into  the  bladder  and  push  its  point  against  the  bladder-wall 
at  the  place  where  it  is  desired  to  make 
the  anastomosis.  At  this  point  incise  the 
bladder.  The  ureter  has  already  been 
prepared  and  has  a  long  suture  pene- 
trating its  wall.  Catch  the  ends  of  this 
suture  in  the  forceps  and  pull  them  into 
the  bladder  and  out  through  the  urethra 

(in  the  male  the  urethra  may  be  opened 

•       1  .  ,        ,  ^  ,    ,  Fig.  663. 

m  the  penneum  for  the  passage  of  the 

forceps;    in  the  female,  the  urethra  serves).      Traction  on  the  suture  pulls  the 

open  end  of  the  ureter  into  the  bladder  and  keeps  it  there  temporarily.     To 

prevent  contraction  of  the  open  end  of  the  urethra  either  cut  it  obliquely  or 

split  it  as  in  the  Van  Hook  operation  for  anastomosis.     Carefully  suture,  with 

several  tiers  of  suture,  the  outer  coats  of  the  bladder  to  the  outer  coats  of  the 

ureter  in'the  Lembert  fashion. 

(B)  This  method  is  similar  to  the  above,  but  a  ureteral  catheter  is  used  in 
place  of  the  forceps.  Pass  a  ureteral  catheter  through  the  urethra  into  the 
bladder  and  bring  its  end  out  through  an  incision  in  the  bladder  at  the  site  of 
anastomosis.  Introduce  the  end  of  the  catheter  into  the  end  of  the  ureter  and 
tie  it  there  with  a  fine  plain  catgut  ligature  (Fig.  663).  Aided  by  traction  on  the 
catheter  pull  the  end  of  the  ureter  into  the  bladder  and  fix  it  there  by  several 
layers  of  sutures  introduced  after  the  Lembert  fashion.  The  ureteral  catheter 
serves  to  drain  the  ureter  and  hold  it  in  position  until  union  takes  place. 

(C)  Van  Hook  Method. — The  end  of  the  ureter  is  split  to  prevent  subsequent 
stenosis.  The  operation  is  practically  the  same  as  in  the  case  of  uretero- 
ureterostomy, except  that  a  line  of  Lembert  sutures,  burying  the  site  of  an- 
astomosis and  the  one  stitch  which  penetrates  all  the  coats  of  the  bladder,  adds 
much  security  (Figs.  664,  665). 

Implantation  of  the  ureter  into  the  intestine,  preferably  into  the  sigmoid, 
is  carried  out  in  the  same  fashion  as  into  the  bladder,  but  the  results  have  uni- 
formly proved  disastrous,  as  infection  invariably  passes  up  the  duct  to  the  kidney, 
von  Maydl's  implantation  of  the  ureters,  plus  a  portion  of  adjacent  bladder- 


556 


OPERATIONS    ON   THE    URETER. 


wall,  into  the  sigmoid  does  not  belong  to  the  same  category  and  gives  good 
results.     It  will  be  descrbed  in  another  chapter. 

Union  of  the  ureter  to  the  skin  is  occasionally  necessary,  but  the  results 
are  bad.  Infection  gains  access  to  the  tube  and  so  to  the  kidney.  The 
operation  has  its  field  of   usefulness,  however.     When  operating,  e.  g.,  on  a 


Urele'' 


Fig.  664. 

cancerous  uterus,  the  ureter  may  be  accidentally  or  intentionally  divided;  the 
condition  of  the  patient  may  not  admit  of  uretero-ureterostomy  or  uretero- 
cystostomy.  Under  such  circumstances  it  may  be  the  best  policy  to  fix  the 
ureter  to  the  skin  and  subsequently  perform  uretero-cystostomy. 

It  has  been  suggested  that  in  all  cases  of  ureteral  anastomosis  success  is 
promoted  if  the  corresponding  kidney  is  exposed  posteriorly,  fixed  to  the  lumbar 
region,  and  drained  through  a  nephrotomy  wound. 


CHAPTER  XLVL 
OPERATIONS  ON  THE  BLADDER. 

ECTOPIA  VESICA  (EXSTROPHY  OF  BLADDER). 

Exstrophy  of  the  bladder  may  be  complete  or  incomplete.  When  incomplete, 
the  case  is  usually  one  of  non-obliterated  urachus,  and  urine  escapes  from  the 
umbilicus.  This  may  be  due  to  some  mechanical  obstacle  to  normal  urina- 
tion, and  treatment  must  be  directed  primarily  to  removal  of  such  obstacle 
(e.  g.,  phimosis).  If  spontaneous  closure  of  the  fistula  at  the  umbilicus  does 
not  occur,  the  passage  may  be  obliterated  by  application  of  the  cautery  or  by 
excision. 

Complete  exstrophy  of  the  bladder  is  a  condition  in  which  the  anterior 
vesical  wall  and  a  corresponding  portion  of  the  parietes  are  absent.  The  an- 
terior surface  of  the  posterior  vesical  wall  pouts  forwards  and  the  urine  escapes 
at  once  as  it  leaves  the  ureters.  As  a  part  of  the  maldevelopment,  one  finds 
the  pubic  bones  ununited  and  the  penis  in  a  condition  of  epispadias.  Opera- 
tions for  the  relief  of  ectopia  vesicae  may  be  divided  into  five  classes: 

I.  The  formation  of  an  anterior  wall  to  the  bladder  by  means  of  cutaneous 
flaps,  the  epidermal  side  being  turned  inwards  to  provide  an  epithelial  lining  for 
the  viscus. 

II.  Union  of  the  edges  of  the  defect,  thus  providing  a  small  cavity,  but  one 
lined  by  the  bladder  mucosa. 

III.  Formation  of  an  anterior  wall  to  the  bladder  from  a  segregated  loop  of 
intestine,  thus  providing  a  mucous  instead  of  an  epidermal  lining. 

rV.  Excision  of  all  the  exposed  bladder  and  transplantation  of  the  ureters 
into  the  penile  gutter. 

V.  Transplantation  of  the  ureters  into  the  intestine  and  excision  of  the 
bladder. 

I.  Wood's  Operation  for  Ectopia  Vesicae. — Object  of  operation  is  to 
provide  an  anterior  wall  to  the  bladder  and  that  such  wall  be  lined  with 
epithelium. 

The  Operation. — Flap  A  (Fig.  666)  is  made  from  the  skin  of  the  abdomen 
above  the  ectopic  bladder  and  has  its  base  near  the  bladder.  In  dissecting  the 
flap  from  the  subjacent  tissues  care  must  be  taken  to  stop  the  dissection  at 
least  1/4  inch  away  from  the  edge  of  the  bladder — i.  e.,  the  hinge  of  flap  A 
should  be  at  least  1/4  inch  distant  from  the  defect  to  be  covered.  The  size  of 
flap  A  should  be  greater  than  the  defect  to  be  covered.  This  is  to  allow  for  the 
shrinkage  which  always  takes  place  in  the  flap.  If  it  is  desired  to  cover  the 
dorsum  of  the  penile  groove  with  the  same  flap,  then  flap  A  may  be  extended 

557 


558 


OPERATIONS  ON  TNE  BLADDER. 


upwards  (the  portion  D  of  flap  A  D  being  used  for  this  purpose).  (Greig 
Smith.)  Flaps  B  and  C  are  obtained  from  the  skin  of  the  abdominal  wall  to 
the  side  of  the  bladder  and  of  flap  A. 

The  margins  of  the  bladder  are  freshened  by  dissection  except  along  the 
edge  opposite  the  hinge  of  flap  A,  and  where  the  penile  groove  or  gutter  enters 
the  bladder.  Flap  A  is  turned  downwards,  the  line  being  the  hinge  or  line  of 
turning,  so  that  the  epithelial  surface  faces  the  bladder  and  the  raw  surface  is 
external.  The  edge  of  the  flap  is  stitched  to  the  freshened  edge  of  the  bladder. 
Special  care  must  be  taken  in  suturing  the  lateral  margins  near  the  base  of  the 


Fig.  666. 


Fig.  667. 


flap,  otherwise  union  does  not  take  place.  Flap  C  is  dissected  from  the  sub- 
jacent tissues  and  slid  over  the  raw  surface  of  flap  A  on  one  side  (Fig.  667). 
The  same  is  done  with  flap  B.  Both  are  sutured  in  position.  The  extensive 
raw  surface  left  on  the  abdominal  wall  by  the  removal  of  flaps  A,  B,  and  C  is 
diminished  by  sliding  inwards  the  surrounding  skin,  and  the  remainder  is 
covered  by  Thiersch's  skin-grafts.  If  the  extension  D  of  flap  A  has  been  pro- 
vided, then  its  edges  are  stitched  to  a  line  of  freshening  on  {each  side  of  the 
penile  gutter. 

II.  Trendelenburg's  Operation. — Note,  in  cases  of  exstrophy,  the  pubic 
bones  are  not  united  at  the  symphysis.  This  want  of  union  prevents  immediate 
closure  of  the  defect  in  the  bladder  and  urethra.  Trendelenburg  overcomes 
the  above  difficulty  as  follows: 

Make  an  incision  about  three  inches  in  length  over  each  sacroiliac  synchon- 
drosis. Open  these  joints  and  divide  their  ligaments  and  the  interarticular 
cartilages.     Press  the  anterior  superior  iliac  spines  together,  so  that  the  pubic 


EXSTROPHY. 


559 


defect  is  obliterated  or  lessened.  Suture  and  dress  the  sacro-iliac  wounds. 
Keep  the  pubic  bones  in  apposition  by  means  of  suitable  binders  applied  to 
the  anterior  borders  of  the  pelvis.  After  the  wounds  have  thoroughly  healed, 
the  exposed  surface  of  the  bladder  may  be  seen  lying  at  the  bottom  of  a  more 
or  less  vertical  groove,  and  may  now  have  its  edges  freshened,  mobilized, 
and  united  by  sutures  in  the  middle  line. 

This  operation  has  given  some  excellent  results. 

J.  W.  Perkins,  finding  division  of  the  sacro-iliac  synchondrosis  too  diffi- 
cult and  dangerous,  divided  the  ilium  close  to  the  synchondrosis  with  the  chisel 
and  obtained  the  same  result. 

Trendelenburg  informs  the  author  that  he  has  used  this  method  of  osteot- 
omy but  considers  it  more  hazardous  than  his  original  procedure.  (For 
much  information  as  to  the  treatment  of  exstrophy,  see  Trendelenburg's  paper 
in  "Annals  of  Surgery,"  August,  1906.) 

Schlange's  Operation. — Schlange  makes  an  incision  along  the  outer  edge 
of  the  lower  part  of  each  rectus  muscle  and  loosens  the  muscle  from  its  sur- 
roundings.    He  then,  with  chisel  and  mallet,  divides  the  bony  insertion  of 


Fig.  608. 


the  muscle  from  the  rest  of  the  pubis  and  slides  the  mobilized  insertion  towards 
the  middle  line,  where  he  fixes  it.  The  mobilization  of  the  recti  muscles  per- 
mits of  the  approximation  of  the  edges  of  the  bladder  and  their  union  after 
freshening. 

Konig  ("Lehrbuch,"  ii,  634)  has  twice  endeavored  to  close  the  pubic 
and  vesical  defects  by  one  operation.  He  says:  "I  divided  the  horizontal 
and  descending  rami  of  the  pubis  through  a  small  wound  over  the  obturator 
foramen.  This  permitted  closure  of  the  defect  in  the  symphysis  when  pres- 
sure was  exerted  on  the  pubis.  The  margins  of  the  bladder  and  of  the 
urethral  groove  were  now  freshened  and  sutured  by  two  lines  of  stitches. 
Unfortunately,  both  patients  succumbed."  The  principle  of  Konig's  proced- 
ure seems  admirable   and   its   danger  does  not  appear  to  the  author  to  be 


56o 


OPERATIONS    ON    THE    BLADDER. 


intrinsically  greater  than  that  of  some  of  the  other  methods  the  ultimate  results 
of  which  are  by  no  means  brilliant. 

Segond's  Operation. — Step  i. — Make  the  incisions  AB,  DC,  BC,  around 
the  ectopic  bladder.  The  points  A  and  D  must  not  be  at  a  lower  level  than 
the  mouths  of  the  ureters.  Freshen  the  edges  of  the  penile  groove,  E  and  F 
(Fig.  668). 

Step  2. — Dissect  the  ectopic  bladder  downwards  as  a  flap.  The  dissection 
must  not  be  carried  below  the  level  of  the  ureteral  mouths. 

Step  3. — Turn  the  bladder  flap  downwards  and  suture  its  edges  to  the 

corresponding    sides    of    the  penile   groove 
(Fig.  669). 

Step  4. — Make  a  transverse  incision 
through  the  base  of  the  malformed  foreskin 
(Fig.  669,  X).  By  making  the  glans  penis 
pass  through  the  hole  in  the  foreskin  the 
latter  is  brought  on  to  the  dorsum  of  !he 
penis  and  its  tissue  can  be  used  to  cover  the 
raw  surface  on  the  back  of  the  new-formed 
dorsum  of  the  penis. 

III.  Rutkowski's  Operation. — Rut- 
kowski's  operation  and  the  similar  one  of 
Mikulicz  have  been  used  with  more  or  less 
success  in  the  treatment  of  exstrophy.  They 
will  be  found  sufficiently  described  in  the 
pages  devoted  to  repair  of  defects  in  the 
bladder- wall. 

IV.  Sonnenburg,  in  a  case  in  which  the 
exposed  vesical  mucosa  protruded  greatly 
and  in  which  no  urinal  could  be  used,  oper- 
ated in  the  following  manner:  Make  an 
incision    all    around    the    exposed    mucous 

membrane,  and  through  this  cut  dissect  the  mucosa  from  the  abdominal 
parietes,  but  do  not  injure  the  peritoneum.  Remove  the  mucosa  completely. 
Dissect  the  lower  ends  of  the  ureters  from  the  surrounding  structures  suffi- 
ciently to  permit  their  implantation  into  the  upper  end  of  the  gutter,  which 
represents  the  urethra,  and  fix  them  there  with  sutures.  Close  the  defect  left 
in  the  abdominal  wall  by  flaps  slid  over  from  its  sides. 

V.  Maydl's  Operation. — Excise  all  the  exposed  vesical  mucosa  except 
that  portion  immediately  around  the  orifices  of  the  ureters  (Fig.  670).  Care- 
fully cleanse  the  wound  and  field  of  operation  after  the  excision  of  the  filthy 
mucous  membrane.  Open  the  abdomen.  Find  the  sigmoid  and  bring  a  loop 
of  it  out  of  the  wound.  By  stripping,  empty  the  gut  of  its  contents.  Apply  an 
intestinal  clamp  or  tape  above  and  below  the  part  selected  for  anastomosis. 
Incise  the  gut  longitudinally.     With  through-and-through  sutures  unite  the 


Fig.  669.- — {Farabeuf.) 


EXSTROPHY. 


561 


edges  of  the  portion  of  bladder-wall  attached  to  the  ureters  to  the  edges  of 
the  wound  in  the  sigmoid  (Fig.  671  and  Fig.  672).  Cover  this  line  of  suture  by 
a  line  of  continuous  Lembert  sutures.  The  result  is  that  the  remnant  or 
ellipse  of  bladder-wall  is  inserted  like  a  patch  into  the  incision  in  the  sigmoid. 
Note  that  no  great  separation  of  the  lower  ends  of  the  ureters  from  their  sur- 
roundings is  required;  the  loop  of  sigmoid  is  brought  down  to  the  ureteral 
portion  of  bladder,  which  is,  of  course,  mobilized.  The 
implantation  of  the  segment  of  bladder-wall  containing 
the  ureters,  instead  of  the  implantation  of  the  ureters 
themselves,  is  the  important  principle  in  the  operation; 
by  it  the  normal  ureteral  valves  or  sphincters  are  retained 
and  infection  is  prevented  from  ascending  the  ureters. 
Several  modifications  of  Maydl's  operation  have  been  sug- 
gested, but  most  of  them  merely  complicate  the  technic. 

VI.  Makkas'  Operation.     (" Zentralblatt  fiir  Chir.," 
1910,  No.  33.) — To  avoid  the  dangers  of  ascending  infec- 
tion inseparable  from  any  method  by  which  the  ureters 
are  made  to  discharge  into  a  cavity  containing  faeces,  Makkas  excludes  the 
caecum  from  the  rest  of  the  intestinal  tract,  unites  its  cavity  to  the  skin  by 
means  of  appendicostomy  and  at  a  later  date  implants  the  ureters  into  the 
segregated  caecum  using  the  appendix  as  a  vent  for  the  escape  of  the  urine. 

The  Operation. — Stage  I. — Step   1. — Open  the  abdomen  by  an  incision 
through  the  right  rectus  muscle. 


Fig.  670. 


Fig.  671. 


Fig.  672. 


Step  2. — Examine  the  caecum.  If  the  caecum  cannot  be  pulled  to  the  middle 
line,  mobilize  it  by  incising  the  parietal  peritoneum  parallel  and  close  to  its 
outer  side. 

Separate  the  caecum  by  blunt  dissection  from  its  posterior  connections 
exactly  as  in  csecectomy  but  carefully  preserve  intact  its  blood  supply. 

Step  3. — Divide  the  ileum  close  to  the  caecum  and  close  both  the  distal  and 
proximal  segments  of  the  gut  Fig.  673. 
36 


562 


OPERATIONS    ON   THE    BLADDER. 


Step  4. — Divide  the  ascending  colon  above  the  caecum  and  close  both  the 
proximal  and  distal  segments  of  the  colon. 

Step  5. — Make  a  lateral  anastomosis  between  the  proximal  segment  of  ileum 
and  the  distal  segment  of  the  colon  (or  the  sigmoid). 

Step  6. — Perform  appendicostomy  bringing  the  appendix  out  through  a 
special  opening.  (Bringing  the  appendix  out  through  an  opening  made  by 
splitting  the  muscles  of  the  abdominal  wall  as  in  the  McArthur-McBurney 
operation  would,  it  appears  to  the  author,  provide  an  excellent  sphincter  to 
the  appendix.) 

If  appendicostomy  seems  inadvisable  or  impossible  because  of  adhe- 
sions, small  size  of  the  appendix,  etc.,  perform 
caecostomy. 

Step  7. — Close  the  abdomen. 
After-treatment. — After  the  lapse  of  ten  days 
pass   a  Nelaton  catheter  through  the   appendix 
daily  and  irrigate  the  Ccecum. 

•  Stage  II. — This  stage  is  practically  identical 
with  the  Maydl  operation  except  that  the  mobi- 
lized portion  of  bladder-wall  attached  to  the 
ureters  is  implanted  into  the  lower  part  of  the 
segregated  caecum  instead  of  into  the  sigmoid. 
When  the  operation  is  completed  the  new  blad- 
der must  be  kept  empty  by  a  catheter  introduced 
through  the  appendix. 

In  Makkas'  case  the  catheter  was  clamped  after  eight  days  and  the  new 
bladder  emptied  every  two  or  three  hours.  At  first  the  capacity  of  the  bladder 
was  only  100  cc.  After  four  weeks  the  capacity  increased  to  300-325  cc.  and 
the  bladder  required  to  be  evacuated  every  three  or  four  hours  through  the 
day  but  not  at  all  during  the  night. 

If  the  catheter  was  removed  while  the  bladder  was  full  there  was  no  escape 
of  urine,  but  this  continence  was  not  absolute  as  drops  of  urine  escaped  when 
the  patient  moved  about.  The  urine  was  not  albuminous  but  contained 
mucus.  The  necessity  of  leaving  the  catheter  in  situ  permanently  is  a  dis- 
advantage, the  lessening  of  the  dangers  of  ascending  infection  is  a  great  advan- 
tage over  the  Maydl  method. 

Remarks. — The  great  objection  to  all  operations  which  endeavor  to  re- 
construct the  bladder,  whether  by  the  use  of  skin -flaps,  by  the  union  of  the 
edges  of  the  imperfect  viscus,  or  by  the  implantation  of  a  segregated  loop  of 
intestine,  is  that  the  result  is  merely  the  formation  of  a  urinary  receptacle  which 
is  devoid  of  any  sphincter  and  hence  cannot  retain  the  urine.  The  only  ad- 
vantages to  be  obtained  by  such  operations  are  the  protection  of  the  vesical 
mucosa  from  injury  and  the  direction  of  the  urine  towards  the  penile  gutter, 
where  it  is  more  feasible  to  attach  a  portable  urinal.  The  operation  of  exci- 
sion of  the  imperfect  bladder  and  transplantation  of  the  ureters  into  the  penile 


Fig.  673. — {Makkas.) 


RUPTURE    OF    BLADDER.  563 

gutter  posseses  both  these  advantages,  and  is  perhaps  a  better  procedure  than 
any  of  those  which  seek  to  reconstruct  the  bladder.  In  performing  plastic 
operations  such  as  those  described  it  is  very  difficult  to  obtain  complete  union 
of  the  transplanted  flaps  to  their  surroundings — hence  fistulse  occur  which, 
unless  closed,  nullify  the  operation.  One  very  grave  objection  to  the  plastic 
operations  which  provide  the  new  bladder  with  an  epidermal  lining  is  that 
urinary  salts  are  inevitably  deposited  on  the  bladder-walls  and  cause  much 
distress.  No  matter  how  carefully  the  flaps  have  been  selected,  fine  hair  is 
liable  to  grow  on  them  and  give  rise  to  complications.  Prima  facie,  one 
would  think  that  when  the  new  bladder  is  lined  with  true  mucous  membrane, 
as  in  Rutkowski's  operation,  the  danger  from  calculus  deposits  would  be 
obviated,  but  experience  shows  this  not  to  be  true;  hence  the  same  objection 
obtains. 

"WTien  simple  uretero-sigmoidostomy  or  uretero-colostomy  is  performed, 
infection  inevitably  passes  up  the  ureters  and  leads  to  a  fatal  issue.  Maydl's 
idea  that  transplantation  of  the  ureters,  plus  their  sphincteric  attachment  to 
the  bladder-walls,  avoids  the  danger  of  infection  ascending  from  the  gut  seems 
correct  and  is  the  operation  of  choice.  The  lower  gut  is  or  becomes  very 
tolerant  to  the  presence  of  urine,  and  the  anal  sphincter  is  capable  of  retaining 
the  urine  for  a  very  respectable  length  of  time. 

Operative  Treatment  of  Rupture  of  the  Bladder. — The  diagnosis  of 
rupture  of  the  bladder  from  the  symptoms  alone  is  not  always  possible  before 
it  is  too  late  to  be  of  aid  in  treatment.  Other  or  operative  means  of  diagnosis 
are  often  essential. 

Diagnosis  by  Operation. — \\Tien  the  patient  has  overcome  initial  shock 
(twelve  to  twenty-four  hours),  or  immediately  if  his  condition  warrants,  diag- 
nosis by  operation  may  be  attempted. 

I.  Injection  of  air  or  water  into  the  viscus.  By  injecting  air  or  water  into 
the  bladder,  should  the  viscus  be  ruptured,  no  globular  tumor  will  form  over 
the  pubis,  and  when  the  water  is  allowed  to  flow  back,  much  less  will  return 
than  was  injected.  Should  there  be  no  rupture,  the  distended  bladder  will 
be  easily  found  in  its  normal  site. 

The  above  operation  has  often  served  a  good  purpose,  but  Schlange  points 
out  that  the  water  or  air  introduced  under  pressure  is  liable  to  cause  separation 
of  peritoneum  from  the  bladder  along  a  ragged  rupture — quite  a  serious  ob- 
jection. The  same  objection  holds  good  against  cystoscopic  examination. 
Another  objection  which  might  be  urged  is  that  in  the  case  of  an  extraperitoneal 
rupture  the  air  or  water  might  easily  distend  the  bladder  to  its  normal  limits 
and  so  lead  to  mistake. 

II.  Several  surgeons  have  recommended  perineal  section  and  examination 
of  the  bladder  through  the  wound.  This  has  but  few  advantages  over  the  next 
method,  and  is  possessed  of  many  disadvantages. 

III.  Suprapubic  cystotomy.  Without  the  aid  of  rectal  distention  the 
surgeon  cuts  into  the  bladder  above  the  pubis.     Under  the  special  circumstances 


564  OPERATIONS    ON    THE    BLADDER. 

(empty  bladder,  etc.)  much  care  must  be  taken  to  "hug"  the  pubis.     The 
bladder  having  been  opened,  the  finger  soon  discovers  any  ruptures  of  its  wall. 

If  intraperitoneal  rupture  is  present,  the  skin-wound  is  enlarged  upwards 
and  the  belly  opened.  Any  bloody  urine  in  the  peritoneal  cavity  is  gently 
sponged  away.  It  may  now  be  necessary  to  put  the  patient  in  the  Trendelen- 
burg position.  The  ragged  wound  of  the  bladder  is  examined,  and  if  necessary, 
some  of  its  bruised  edges  trimmed  away.  A  line  of  chromicized  catgut  sutures 
is  put  in  place.  These  sutures  pass  through  all  the  coats  of  the  viscus  except 
the  mucosa.  A  line  of  Lembert  sutures  is  inserted  superficially  to  protect 
the  deep  ones.  The  abdominal  cavity  is  now  cleaned,  either  by  flushing  with 
normal  salt  solution  or  by  gently  sponging  with  gauze  pads.  The  laparotomy 
wound  is  closed  with  or  without  drainage. 

In  extraperitoneal  rupture  the  danger  is,  of  course,  from  infiltration  of  urine. 
The  suprapubic  cystotomy  guides  the  surgeon  to  the  threatened  or  afTected 
regions  and  he  can  at  once  provide  free  drainage  by  appropriate  incisions  and 
by  packing  such  regions  with  iodoform  gauze.  Bleeding  must  be  stopped  either 
by  ligature,  pressure,  or  packing. 

How  ought  the  suprapubic  wound  of  the  bladder  to  be  treated?  In  such 
cases  it  ought  always  to  be  left  open.  Schlange  unites  the  vesical  mucous 
membrane  to  the  skin  by  a  few  stitches.  The  bladder  itself  is  lightly  filled 
with  iodoform  gauze,  so  that  it  is  constantly  emptied  of  urine  by  capillary 
drainage.  Permanent  catheterization  of  the  ureters  and  packing  of  the  bladder 
is  a  tempting  procedure  which  would  be  liable  to  lead  to  ureteritis  and 
pyelitis. 

Suprapubic  Cystotomy. — The  operation  of  suprapubic  cystotomy  may 
be  required  for  the  removal  of  calculi  or  neoplasms  from  the  bladder,  for  the 
removal  of  enlarged  lobes  of  the  prostate,  for  purposes  of  exploration  and  the 
treatment  of  various  vesical  lesions  and  for  the  carrying  out  of  retrograde 
catheterization,  etc.  Preliminary  treatment  varies  according  to  circumstances 
— in  one  case,  e.  g.,  prostatectomy,  it  is  wise  to  endeavor  to  cleanse  the  bladder 
by  appropriate  means;  in  another  case,  e.  g.,  bleeding  villous  tumors,  such  treat- 
ment is  calculated  to  encourage  serious  hemorrhage;  in  cases  of  cystitis  where 
treatment  per  uretJiram  is  a  failure,  the  cystotomy  is  undertaken  to  provide 
drainage,  and  the  failure  of  other  treatment  means  failure  to  cleanse  the  bladder. 
In  all  cases  the  large  intestine  should  be  well  emptied  before  operation.  Local 
or  general  anaesthesia  is  requisite. 

Shave  the  pubis  and  cleanse  the  hypogastrium  and  the  penis.  Introduce 
a  catheter  and  irrigate  the  bladder  with  warm  salt,  boracic  acid,  or  Thiersch's 
solution.  When  the  irrigation  is  finished,  distend  the  viscus  with  the  solution 
or  with  air.  Remember  that  in  cases  of  old  cystitis  the  bladder-wall  is  often 
very  weak  and  cannot  safely  be  greatly  distended.  A  good  plan  is  to  test 
the  capacity  of  the  bladder  before  any  anaesthetic  is  administered  and  act 
according  to  the  knowledge  gained.  Many  surgeons  prefer  air  distention  to 
fluid.     Air  is  said  to  bring  the  viscus  more  easily  against  the  abdominal  wall. 


CYSTOTOMY.  565 

and  when  the  bladder  is  opened,  there  is  no  gush  of  infected  fluid  over  the 
field  of  operation.  These  advantages  are  of  no  great  value  and  most  surgeons 
prefer  the  warm  aqueous  solutions,  which  are  more  easily  sterilized  and  man- 
aged than  is  the  air.  Having  distended  the  bladder  within  the  limits  of  safety, 
withdraw  or  plug  the  proximal  end  of  the  catheter  and  tie  a  rubber  band 
around  the  penis  to  prevent  the  escape  of  the  water  or  air.  If  the  catheter 
is  left  in  situ,  it  acts  as  a  guide  to  the  bladder. 

Some  surgeons  endeaver  to  lift  the  bladder  still  more  against  the  belly-wall 
by  inserting  a  rubber  bag  into  the  rectum  and  distending  it  with  air  or  water. 
This  procedure  is  unnecessary  and  has  led  to  many  serious  injuries  being 
inflicted  on  the  rectum.  Even  distention  of  the  bladder  itself  is  not  absolutely 
necessary,  but  when  possible,  is  always  of  immense  value,  as  it  pushes  the 
vesical  fold  of  peritoneum  upwards  and  makes  the  extraperitoneal  exposure 
of  the  bladder  easy. 

Place  the  patient  in  the  Trendelenburg  position,  as  this  enlarges  the  ex- 
traperitoneal area  through  which  one  must  proceed. 

I.  Vertical  Incision. — Beginning  on  the  pubis  near  its  upper  edge,  make 
a  vertical  median  incision  upwards  for  from  3  to  4  inches.  Expose  and  divide 
the  anterior  layer  of  deep  fascia  and  separate  the  pyriform  and  recti  muscles. 
Carefully  pick  up  and  divide  the  deep  layer  of  fascia,  thus  exposing  the 
prevesical  fat.  Hook  the  finger  behind  the  pubis  and  pull  upwards  the  prevesi- 
cal fat,  and  with  it  the  vesical  fold  of  peritoneum.  Recognize  the  peritoneal 
fold  and  retract  it  upwards  out  of  danger.  Rarely  the  peritoneal  fold  may  be 
adherent  to  the  pubis  and  must  be  freed  by  blunt  or  sharp  dissection.  During 
the  manoeuvres  described  the  peritoneal  cavity  may  be  accidentally  opened. 
This  accident  is  only  important  if  not  promptly  recognized  and  corrected  by 
a  few  carefully  placed  sutures.  Expose  the  anterior  wall  of  the  bladder  by 
bluntly  dissecting  through  the  fat  in  front  of  it.  Once  the  peritoneal  fold  is 
recognized  and  retracted,  do  not  hug  the  posterior  surface  of  the  pubis  too 
closely,  as  to  do  so  means  exposure  of  the  bladder  at  a  level  difficult  of  access 
and  where  it  is  very  vascular;  it  also  means  the  formation  of  a  ragged  pouch 
difficult  to  drain,  in  very  unresisting  tissues.  The  nearer  its  dome  the  bladder 
can  be  exposed  extraperitoneally,  the  better.  The  bladder  will  be  recognized 
by  its  globular  form,  if  distended,  or  by  the  catheter  in  it  if  it  is  not  distended. 
It  has  a  brownish-red  color,  and  one  can  see  the  longitudinal  fibres  of  the  de- 
trusor muscle  on  its  surface. 

The  bladder  having  been  freely  exposed,  pick  up  a  portion  of  its  wall  with 
a  sharp  hook  or  volsellum,  and  witli  a  strongly  curved  needle  pass  two  long 
sutures  through  its  walls  parallel  to  the  direction  in  which  it  is  desired  to  incise 
the  bladder.  These  sutures  serve  as  convenient  tractors.  Jacobson  omits 
their  use,  as  he  thinks  they  do  more  damage  than  forceps  attached  to  the  edges 
of  the  incision.  The  writer  has  never  seen  harm  result  from  the  thread  tractor, 
and  they  are  certainly  much  more  convenient  than  forceps,  which  always 
impede  further  operative  work.     Incise  the  bladder,  either  vertically  or  trans- 


566  OPERATIONS    ON    THE    BLADDER. 

versely,  sufficiently  to  admit  one  or  two  fingers.  The  transverse  incision  is  the 
better;  it  is  more  readily  enlarged  and  more  readily  closed.  If  the  vertical 
incision  is  chosen  and  requires  enlargement,  such  enlargement  must  be  done 
dov^^nwards  in  an  aw^kward  location,  deeply  behind  the  pubis.  If  for  the 
purposes  of  the  subsequent  steps  of  the  operation  (removal  of  calculi,  tumors, 
etc.)  the  wound  in  the  parietes  is  found  too  narrow,  more  space  may  be  ob- 
tained by  making  a  number  of  small  incisions  or  nicks  in  the  edges  of  the 
recti  muscles,  or  those  muscles  may  be  separated  from  their  pubic  insertion. 
More  room  has  also  been  obtained  by  subperiosteal  excision  of  part  of  the 
pubic  bones.     Such  extreme  measures  to  gain  space  are  rarely  necessary. 

The  treatment  of  the  various  lesions  met  with  in  the  bladder  will  be  dis- 
cussed later. 

Treatment  of  the  Wound  in  the  Bladder. — If  the  bladder  is  not  seriously 
infected  or  the  wound  has  not  been  greatly  contused,  e.  g.,  by  the  removal 
of  stones,  etc.,  the  opening  may  be  closed  in  whole  or  in  part.  If  marked  vesical 
infection  is  present  or  if  the  walls  are  much  contused,  it  may  be  necessary  or 
judicious  to  leave  the  wound  wide  open. 

Closure  of  the  Vesical  Wound. — If  the  mucosa  is  inclined  to  bleed,  unite  the 
edges  of  the  wound  in  it  by  a  row  of  continuous  fine  catgut  sutures.  With 
fine  catgut  on  a  rounded  needle  (one  without  cutting-edges)  unite  the  edges 
of  the  wound  in  the  muscular  wall  of  the  bladder.  If  it  can  be  accomplished 
without  undue  tension,  bury  the  layer  of  muscle  suture  by  a  row  of  stitches  in- 
serted in  the  Lembert  fashion  and  composed  of  fine  silk  or  celluloid  hemp. 
It  is  very  desirable  to  have  an  inverted  wound  •with,  wide  surfaces  in  apposi- 
tion. Close  the  wound  in  the  parietes  after  providing  tubular  or  cigarette 
drainage  for  the  prevesical  space.  If  the  bladder  is  completely  closed  as  above, 
urine  must  be  drawn  off  frequently  by  the  catheter  or  permanent  catheteri- 
zation must  be  kept  up.  It  is  a  very  good  and  eminently  safe  precaution  to 
provide  perineal  drainage  before  closing  the  vesical  wound.  This  may  be  done 
as  follows:  Through  the  suprapubic  opening  pass  a  closed  forceps  through 
the  internal  meatus  into  the  membranous  urethra.  Place  the  patient  in  the 
lithotomy  position.  With  the  forceps  above  mentioned  make  prominent  the 
membranous  urethra  just  behind  the  bulb.  Cut  down  on  the  point  of  the 
forceps  and  with  them  seize  and  pull  into  the  bladder  the  end  of  a  soft-rubber 
catheter  (No.  36  Fr.  or  larger).  With  a  stitch  fix  the  catheter  to  the  perineal 
wound.     Proceed  with  the  closure  of  the  suprapubic  wound. 

If  it  is  desired  to  establish  suprapubic  drainage,  partially  close  the  wound, 
if  it  is  too  large,  and  introduce  into  the  bladder  a  1/4-inch  rubber  tube  or  even 
two  such  tubes.  The  ends  of  the  tubes  should  not  impinge  against  the  base 
of  the  bladder  and  they  should  be  cut  so  as  to  be  bevelled  and  be  provided  with 
lateral  openings.  In  such  cases  it  is  wise  to  sew  the  bladder  to  the  parietal 
fascia  around  the  point  of  exit  of  the  tubes.  This  is  to  prevent  leakage  of 
urine  into  the  abdominal  wound.  When  the  vesical  wound  is  not  large  and 
drainage  is  desired,  one  may  proceed  as  follows:     Dress   a  1/4-inch  rubber 


SUPRAPUBIC   LITHOTOMY.  567 

drain  by  covering  it  with  two  or  three  layers  of  gauze;  this  in  turn  covered 
by  rubber  tissue  (practically  a  cigarette  drain  with  a  tube  through  its  centre). 
Introduce  the  end  of  the  drain  a  very  short  distance  into  the  bladder.  With 
catgut  suture  the  edges  of  the  bladder  wound  to  the  drain  or  its  dressing.  Push 
the  tube  a  little  further  into  the  bladder;  this  inverts  the  edges  of  the  bladder 
wound.  In  the  Lembert  fashion,  with  catgut,  suture  the  surface  of  the  blad- 
der all  around  the  wound  to  the  tube.  We  thus  have  a  double  line  of  sutures 
(catgut)  uniting  the  bladder  to  the  tube  and  forming  a  water-tight  joint.  Fix 
the  ends  of  the  last  row  of  sutures  to  the  parietal  fascia  so  as  to  keep  the 
bladder  in  contact  with  the  abdominal  wall  and  close  the  wound  in  the  latter. 
The  water-tight  joint  around  the  tube  is  intended  to  keep  urine  and  infection 
away  from  the  prevesical  fat  and  the  abdominal  wound  until  healing  has 
progressed,  to  some  extent,  at  least. 

If  from  any  cause  it  is  deemed  proper  to  leave  the  vesical  wound  entirely 
open,  it  is  wise  to  attach  its  edges  to  the  fascia  abdominalis  by  a  few  points 
of  suture,  and  to  pack  its  cavity  loosely  with  iodoform  gauze. 

It  is  easy  to  attach,  with  a  glass  joint,  a  long  piece  of  tubing  to  the  bladder 
drain  and  by  siphonage  conduct  the  urine  to  a  suitable  receptacle  placed  be- 
neath the  bed. 

II.  Transverse  Incision. — Bardenheuer  and  many  other  surgeons  prefer 
a  transverse  to  a  vertical  incision,  as  more  room  is  obtained.  The  disadvantage 
of  this  method  is  the  liability  to  subsequent  hernia.  In  cases  of  intravesical 
tumor  the  transverse  incision  in  specially  good.  Place  the  patient  in  Tren- 
delenburg's position.  Make  a  slightly  curved  horizontal  incision  through  the 
skin  from  the  neighborhood  of  one  external  inguinal  ring  to  the  other,  imme- 
diately above  and  parallel  to  the  pubic  bones.  Divide  the  fascia  covering  the 
recti  muscles.  Separate  the  recti,  pyramidales,  and  the  linea  alba  from  the 
bone.  The  retraction  of  the  muscles  gives  a  wide  space  for  the  subsequent 
work;  if  more  space  is  required,  separate  the  recti  from  each  other  vertically. 
The  rest  of  the  operation  is  the  same  as  that  already  described. 

Suprapubic  Lithotomy. — This  operation  is  practically  that  of  cystotomy 
plus  the  removal  of  the  stone.  If  the  calculus  present  is  believed  to  be  large, 
the  transverse  incision  is  the  better,  as  it  gives  more  room.  It  is  bad  practice 
to  drag  a  stone  out  through  too  small  a  incision,  as  the  resulting  trauma  is 
far  more  noxious  than  the  making  of  a  large  opening  by  a  sharp,  purposeful 
cut.  Calculi  must  be  removed  by  appropriate  forceps  or  scoop  (Figs.  674 
and  675).  In  the  absence  of  these  special  and  very  convenient  instruments, 
common  sense  informs  us  that  the  same  object  may  be  attained,  though  less 
expeditiously,  by  the  use  of  the  fingers,  ordinary  forceps,  or  a  loop  of  wire. 
The  suprapubic  route  insures  a  good  survey  of  the  interior  of  the  bladder,  and 
hence  prevents  the  not  uncommon  fault  of  overlooking  a  second  or  third  stone. 
Remember  that  a  second  calculus  may  lie  encysted  in  the  pouch  behind  the 
prostate.  When  there  is  no  great  infection  present,  it  is  good  practice  to  es- 
tablish perineal  drainage  in  the  manner  already  described  and  close  the  supra- 


568 


OPERATIONS  ON  THE  BLADDER. 


pubic  wound.  If  infection  is  considerable  suprapubic  drainage  ought  to  be 
established,  either  alone  or  in  combination  with  perineal.  The  after-treatment 
consists  in  keeping  the  bladder  clean;  the  cystitis  usually  quickly  subsides  on 
removal  of  its  cause. 

Occasionally  the  stone  may  lie  in  a  congenital  or  acquired  diverticulum. 
If  this  is  the  case  Fenwick  advises  fragmentation  of  the  stone  in  situ  by  means 
of  a  chisel  lightly  struck  by  a  mallet.  In  one  case  where  the  stone 
was  unintentionally  broken  the  author  found  great  difficulty  in  remov- 
ing the  fragments.  In  another  case  where  a  stone,  33/4  xi  1/4  x 
I  1/2  X  2  3/4  inches  in  diameter,  lay  in  a  diverticulum  the  mouth  of 
which  was  only  large  enough  to  admit  the  forefinger,  forcible  dilata- 
tion of  the  opening  permitted  removal  of  the  calculus,  hemorrhage 
was  trivial,  and  no  evil  seemed  to  result. 

Suprapubic  Cystotomy  for  Benign  Neoplasms. — Benign  neo- 
plasms are  usually  pedunculated;  they  may  be  single  or  multiple, 
sometimes  being  very  numerous,  filling  up  most  of  the  space  in  the 
bladder.  Most  vesical  papillomata  bleed  easily,  and  on  account  of 
this  tendency  it  may  be  convenient  to  throw  into  the  bladder,  im- 


FlG.  674. 


Fig.  675. 


mediately  before  operation,  a  small  quantity  of  a  solution  of  adrenalin.  The 
advantage  gained  by  the  use  of  adrenalin  is  that  less  bleeding  occurs  during 
the  active  operation  and  hence  the  surgeon  sees  better  what  he  is  doing; 
whether  hemorrhage  is  more  or  less  liable  to  occur  secondarily,  i.  e.,  after  the 
effects  of  the  drug  have  worn  off,  is  another  matter,  and  not  yet  proved. 

The  bladder  is  opened  preferably  by  the  transverse  incision,  because  of 
the  free  access  obtained.  When  the  tumor  is  pedunculated,  seize  its  base  in 
a  curved  clamp  and  cut  away  the  free  portion  of  the  growth.  Never  drag  upon 
the  forceps  so  as  forcibly  to  tear  away  the  growth.  Sometimes  the  tumor  is 
so  delicate  that  mere  pressure  with  the  forceps  separates  it  from  its  base. 
WTien  possible,  excise  with  scissors  the  portion  of  the  pedicle  grasped  by  the 
forceps  and  close  the  wound  in  the  mucous  membrane  with  one  or  two  points 
of  catgut  suture.  The  finger  of  an  assistant  pushing  up  the  bladder  from  the 
rectum  may  aid  greatly  in  this  work  when  the  site  of  the  trouble  is  on  tlie 


CYSTOTOMY.  569 

posterior  bladder-wall.  If  the  tumor  is  sessile  or  has  a  broad  base,  cut  it 
away  with  scissors,  as  close  to  the  bladder-wall  as  possible,  and  cauterize  the 
stump  with  the  thermocautery.  Some  surgeons  operate  on  tumors  and  various 
bladder-lesions  through  a  kind  of  coflfer-dam,  so  as  to  avoid  urine  and  blood 
from  other  parts  obscuring  the  field  of  operation.  The  model  on  which  all 
such  cofifer-dams  are  made  is  the  old  Ferguson's  tubular  vaginal  speculum, 
passed  through  the  abdominal  wound  and  enclosing  in  its  distal  opening  the 
area  to  be  attacked.  The  coffer-dam  undoubtedly  is  a  great  aid  in  operating, 
but  it  has  the  serious  disadvantage  of  requiring,  for  many  purposes,  the  use 
of  special  scissors  and  forceps  to  permit  of  work  being  done  through  its  narrow 
lumen.  After  the  removal  of  tumors  drainage  is  essential,  and  the  use  of 
various  antiseptic  and  more  especially  astringent  douches  is  advantageous. 
Repeated  operations  may  be  necessary  before  all  the  neoplasms  are  removed. 
If  hemorrhage  is  alarming,  the  bleeding  areas  may  be  packed  with  iodoform 
gauze. 

Nitze  and  Sonnenburg  write  as  follows  ("Handbuch  der  practischen  Chir.," 
iii,  838):  "Passing  one  or  two  fingers  gently  into  the  bladder,  one  informs 
himself  as  to  the  nature  of  the  tumor  and  the  manner  of  its  origin  on  the  bladder- 
wall.  If,  as  is  very  common,  the  tumor  is  a  large,  solid,  villous  growth  with  a 
pedicle,  or  if  a  pedicle  can  be  formed  by  cautious  pulling  on  the  tumor,  catch  it 
gently  but  firmly  between  the  fore-  and  middle  fingers  and  pull  it  upwards 
from  the  mucous  membrane  for  such  a  distance  that  a  curved  forceps  or  clamp 
can  be  applied  to  the  pedicle  between  the  fingers  and  the  mucosa.  By  careful 
but  strong  traction  on  the  locked  forceps  endeavor  to  bring  the  base  of  the 
tumor  up  to  the  level  of  the  external  wound.  It  is  astonishing  how  far  up 
continued  traction  can  bring  the  mucous  membrane  of  the  base  of  the  bladder 
without  injury  to  the  patient.  If  the  tumor  is  large,  it  often  prevents  ocular 
inspection  of  the  mucosa  around  its  base  and  the  necessary  recognition  of  the 
ureteral  openings.  Under  these  circumstances  one  tears  away  the  villous  masses 
from  their  pedicle;  no  hemorrhage  results  because  the  forceps  are  in  situ  com- 
pressing the  pedicle.  The  whole  field  of  operation  being  exposed  to  view, 
pass  two  silver  wires  through  the  portion  of  bladder-wall  that  is  pulled  up 
by  the  forceps,  at  a  considerable  distance  from  the  pedicle,  and  then  with  the 
knife  or  cautery  (knife-blade)  excise  the  pedicle,  and  with  it  some  of  the  sur- 
rounding mucosa.  Injury  to  the  ureters  can  usually  be  avoided  during  the 
extirpation  of  benign  neoplasms  even  if  the  latter  are  situated  at  their  orifices, 
but  their  injury  generally  does  no  harm;  even  complete  excision  of  the  ureteral 
orifices  is  well  borne.  After  extirpation  of  the  base  of  the  tumor  the  silver 
wires  already  in  place  prevent  retraction  of  the  field  of  operation  and  thus 
hemorrhage  can  be  more  readily  attended  to,  and  sutures  introduced,  after 
which  the  silver  wires  are  removed." 

Malignant  neoplasms  cannot  be  efficiently  treated  in  the  above  fashion. 
All  nibbling,  hesitating  methods  are  worse  than  useless,  merely  stimulating 
to  increased  rapidity  of  growth.     The  principles  of  operation  are  identical 


570 


OPERATIONS  ON  THE  BLADDER. 


with  those  for  operation  on  carcinoma  located  elsewhere,  viz.,  wide  and  complete 
removal;  partial  or  total  cystectomy. 

The  most  serious  form  of  non-malignant  ulcer  of  the  bladder  is  the  tuber- 
culous, and  this  will  be  taken  as  the  type  in  discussing  the  operative  treatment 
of  ulcer.  As  in  other  locations,  so  also  in  the  bladder,  rest  is  a  sine  qua  non 
of  treatment.  Drainage  through  the  suprapubic,  the  perineal,  or  through 
both  routes  is  the  best  means  of  obtaining  the  necessary  rest,  and  in  cases  of 
simple  ulceration  may  be  essentially  all  the  treatment  required.  When  the 
ulceration  is  tuberculous,  further  operative  treatment  is  necessary-.  Open 
and  explore  the  bladder.  A  cold  electric  lamp  introduced  through  the  wound 
is  a  great  aid,  as  also  is  light  from  a  head-mirror  or  lamp.  If  the  ulcer  is  soli- 
tary, limited  in  extent,  and  situated  on  the  anterior  part  of  the  bladder  from 
which  the  peritoneum  can  be  stripped,  it  is  wise  to  excise  the  affected  portion 
of  vesical  wall  and  close  the  wound  completely  after  providing  perineal  drain- 
age. If  the  ulcer  is  situated  at  the  base  of  the  bladder — and  this  is  commonly 
the  case — cauterize  it  with  the  thermocautery  or  with  pure  formalin  and  rub 
iodoform  into  it.  The  subsequent  local  treatment  must  consist  of  drainage 
and  lavage  with  suitable  antiseptic  lotions.  General  treatment  is  of  the  utmost 
importance — good  food,  fresh  air,  tonics,  and  some  form  of  guaiacol  are  our 
main  reliances. 

The  natural  resisting  power  of  the  bladder  against  tuberculosis  is  well 
illustrated  in  cases  of  tuberculous  nephritis  and  ureteritis  in  which  secondary 
lesions  appear  in  the  bladder  around  the  ureteral  orifices.  After  nephrectomy 
and  ureterectomy  the  vesical  lesions  often  disappear  spontaneously.  This 
fact  encourages  us  in  the  treatment  of  vesical  tuberculosis. 

Suprapubic  Prostatectomy  and  Prostatotomy.— Open  the  bladder  and 
explore  so  as  to  recognize  the  variety  of  prostatic  enlargement  present  and 
the  presence  or  absence  of  vesical  calculi.  If  the  latter  are  present,  remove 
them. 

I.  Enlarged  Pedunculated  Middle  Lobe. — This  lobe  may  be  the  sole  obstacle 
to  urination,  forming  a  valve  which  occludes  the  vesical  meatus. 

Method  A:  Cut  through  the  pedicle  with  scissors  and  remove  the  lobe. 
Hemorrhage  is  easily  controlled  by  temporary  pressure  with  pads  wrung  out 
of  hot  water. 

Method  B:  Incise  or  tear  through  the  mucosa  covering  the  lobe  and  shell 
it  out  with  the  finger.  This  method  is  available  whether  the  hypertrophied 
lobe  is  pedunculated  or  not. 

Never  omit  to  examine  the  prostatic  urethra,  lest  the  lateral  lobes  impinge 
upon  it  and  require  removal. 

II.  Enlarged  Lateral  Lobes  with  or  without  Enlargement  oj  the  Middle  Lobe. — 
Introduce  a  gum-elastic  catheter  into  the  bladder  through  the  urethra,  to  act 
as  a  guide  to  the  position  of  the  prostatic  urethra.  Make  an  incision  through 
the  mucous  membrane  over  the  most  prominent  part  of  the  swelling.  With 
the  finger,  aided  if  necessary  by  closed  blunt-pointed  scissors,  peel  the  mucosa 


CYSTECTOMY.  57 1 

from  the  surface  of  the  prostate.  Insinuate  the  tinger  through  the  mucosal 
wound,  between  the  prostate  and  the  urethra,  and  separate  these  structures. 
In  the  same  way  separate  the  outer  surface  of  the  prostate  from  its  surroundings, 
the  finger  passing  between  the  true  and  false  prostatic  capsules.  The  fingers 
of  an  assistant  should  be  passed  through  the  anus  to  elevate  and  steady  the 
prostate.  Working  as  above,  the  prostate  may  be  removed  in  one  piece  or  in 
two  or  more  sections.  Freyer  is  often  successful  in  leaving  the  prostatic  urethra 
intact,-  though  when  it  is  injured  no  harm  seems  to  result.  Moynihan  removes 
the  prostatic  urethra  with  the  gland.  It  is  claimed  that  when  the  two  lateral 
lobes  are  removed  separately  the  ejaculatory  ducts  are  not  destroyed.  The 
author  for  a  number  of  years  has  omitted  the  use  of  any  catheter  or  sound  as  a 
guide.  He  introduces  his  finger  through  the  suprapubic  wound  into  the  internal 
or  vesical  meatus,  with  his  finger  nail  penetrates  the  mucosa  and  shells  out 
the  enlarged  lobes.  In  this  procedure  he  has  the  support  of  L.  L.  McArthur 
("Surg.  Gyn.  Obst.,"  Ap.  lo,  p.  412).  Hemorrhage  is  easily  controlled 
by  temporary  pressure  with  pads  wrung  out  of  hot  water.  Freyer  intro- 
duces a  large  drain  into  the  bladder  through  the  abdominal  wound  and 
sutures  the  vesical  wound  around  it.  Through  the  tube  irrigation  with  hot 
water  may  be  practised  and  any  blood-clots  removed.  The  drain  is  kept  in 
position  for  about  one  week,  when  it  is  removed  and  the  wound  permitted  to 
close.  Very  excellent  results  have  been  reported  from  this  apparently  severe 
operation.  Fuller,  after  completing  the  enucleation  of  the  prostate,  establishes 
perineal  drainage  and  closes  the  suprapubic  wound.  In  cases  in  which  there 
is  much  infection  it  is  probably  best  to  maintain  both  perineal  and  suprapubic 
drainage  for  a  few  days.  Prostatectomy  via  the  perineal  route  will  be  described 
on  another  page. 

Cystectomy. — Cystectomy  may  be  partial  or  complete. 

Partial  Cystectomy. — This  operation  is  most  commonly  indicated  in  cases 
of  circumscribed  malignant  neoplasm,  and  whenever  feasible  should  be  carried 
out  extraperitoneally.  The  anterior  wall,  most  of  the  fundus,  and  some- 
times even  part  of  the  posterior  wall  of  the  bladder  may  be  exposed  without 
opening  the  peritoneal  cavity.  Expose  the  bladder  as  in  suprapubic  cystotomy. 
Carefully  pull  the  prevesical  fold  of  peritoneum  upwards,  and  by  blunt  dis- 
section separate  its  vesical  layer  from  the  bladder  to  the  desired  extent.  If 
the  peritoneum  is  accidentally  torn,  the  tear  must  be  at  once  closed  with  sutures. 
Ha\dng  exposed  the  bladder  at  the  site  of  the  tumor  (anterior  wall  or  fundus) 
open  it  and  remove  the  whole  thickness  of  the  diseased  portion,  making  the 
necessary  cuts  in  healthy  tissue.  Remove  too  much  rather  than  too  little  tissue 
along  with  the  neoplasm.  Close  the  wound  by  sutures  exactly  as  in  suprapubic 
cystotomy,  after  providing  for  drainage — preferably  through  the  perineum. 

If  the  neoplasm  has  infiltrated  the  bladder- wall  so  as  to  attack  the  peritoneal 
covering  and  its  location  is  favorable,  the  operation  may  still  be  accomplished 
practically  extraperitoneally.  Expose  the  bladder  and  reflect  the  peritoneum 
from  it  except  where  it  is  adherent  over  the  site  of  the  neoplasm;  \\i\h.  scissors 


572  OPERATIONS    ON    THE    BLADDER. 

cut  around  the  site  of  adhesions;  with  sutures  close  the  gap  in  the  peritoneum 
and  remove  the  diseased  cystic  wall  as  already  described. 

When  the  disease  aiJects  the  posterior  bladder- wall,  but  does  not  infiltrate  the 
peritoneal  covering,  it  may  be  removed  as  follows:  Apply  a  solution  of  adrenalin 
to  the  bladder  so  as  to  control  hemorrhage,  not  from  any  fear  of  loss  of  blood, 
but  to  keep  blood  from  obstructing  the  view.  Incise  the  bladder-wall  all 
around  the  neoplasm,  cutting  in  healthy  tissue.  Cut  down  to  but  not  through 
the  peritoneal  coat.  Remove  the  disease,  along  with  the  whole  thickness  of 
the  wall,  minus  the  peritoneal  covering.  Close  the  wound  by  a  layer  of  sutures 
(catgut)  involving  the  muscular  coats  alpne,  and  one  involving  the  mucosa 
alone.  Should  the  peritoneum  be  accidentally  opened,  close  it  at  once  by  a 
few  catgut  or  fine  silk  sutures.  The  operation  as  above  described  involves 
more  precise  suturing  than  most  surgeons  are  capable  of  doing.  It  must  re- 
quire marvelous  skill  to  suture  with  precision  the  various  vesical  coats  when  the 
work  has  to  be  done  at  the  bottom  of  a  deep  cavity.  If  the  peritoneal  covering 
is  uninjured,  probably  the  best  method  to  pursue  is  to  make  the  stitches  involve 
the  muscular  and  mucous  coats.  These  stitches  will  probably  not  secure 
complete  union;  there  will  be  separation  of  the  edges  in  time,  but  they  will 
lessen  the  size  of  the  defect  and  so  hasten  recovery.  If  it  is  possible  to  pull 
the  wound  up  towards  the  surface  of  the  body,  then  of  course  its  closure  is  easy. 

When  the  tumor  is  situated  at  the  trigone,  the  operation  is  very  much  as 
above  described.  One  cuts  through  the  bladder-wall  layer  by  layer  until  the 
perivesical  fat  is  reached,  and  then  removes  the  disease.  If  the  ureter  is 
involved  in  the  disease,  pass  a  catheter  into  it  and  dissect  it  free  from  its  sur- 
roundings for  about  two  inches;  remove  such  part  of  it  as  may  be  diseased; 
secure  its  ends  temporarily  by  a  thread.  After  the  resection  of  the  bladder- 
wall  is  completed  unite  the  ureter  once  more  to  the  bladder.  Occasionally  it 
has  been  necessary  to  anastomose  the  ureter  to  the  rectum  or  skin;  this  is  very 
undesirable. 

Transperitoneal  Partial  Cystectomy. — Francis  Harrington  ("Annals 
Surg.,"  1893),  struck  by  the  safety  with  which  wounds  of  the  bladder,  accident- 
ally inflicted  during  laparotomy,  may  be  sutured,  boldly  opened  the  bladder 
through  the  peritoneal  route.  C.  H.  Mayo  followed  Harrington  with  a  number 
of  successful  operations  for  vesical  neoplasms. 

The  Operation. — Wash  out  and  empty  the  bladder  completely.  Put  the 
patient  in  Trendelenburg's  position. 

1.  Make  a  median  incision  between  the  pubis  and  umbilicus  about  6 
inches  long.  Open  the  peritoneum.  Thoroughly  pack  with  gauze  to  keep 
the  intestines  away  and  to  protect  the  belly  cavity. 

2.  Pick  up  the  bladder  with  two  volsella  and  incise  it  between  them.  The 
incision  is  median  and  about  2  inches  in  length.  With  gauze  mop  out  any 
fluid  in  the  bladder.  Enlarge  the  incision  in  the  bladder  upwards  and  down- 
wards until  the  cut  equals  one-third  or  more  of  the  vertical  circumference  of  the 
viscus. 


CYSTECTOMY. 


573 


3.  If  the  tumors  are  pedunculated  and  benign,  cut  through  them  flush  with 
the  vesical  mucosa  and  burn  the  wound  with  a  cautery  (Fig.  676). 

If  the  tumors  are  sessile  and  benign,  remove  them  and  burn  their  site. 
If  the  tumors  are  malignant,  excise  them  with  the  mucosa  by  means  of  the 


Fig.  676.— (.1/ayo.) 


cautery  knife.     Do  not  try  to  destroy  the  growth  with  the  cautery,  but  lift  it 
up  with  forceps  and  dissect  it  away,  using  the  cautery  as  a  knife. 

4.  Close  the  wound  in  the  bladder  by  through-and-through  catgut  stitches 
introduced  in  the  Connel  fashion  (Fig.  677).  Put  in  a  second  layer  of  stitches 
(hemp)  in  the  continuous  Lembert  or  Gushing  fashion.  At  the  lower  end  of 
the  cut  where  the  bladder  is  not  covered  with  peritoneum  it  is  easy  to  so  loosen 


574 


OPERATIONS    ON    THE    BLADDER. 


the  parietal  peritoneum  continuous  with  the  vesicle  peritoneum  that  it  can  be 
made  to  lie  on  the  bladder  and  permit  the  continuation  of  the  Lembert  suture 
until  the  bladder  is  completely  closed.  Usually  no  drainage  is  required,  but 
should  cystitis,  etc.  demand  drainage,  provide  for  it  in  the  following  manner: 


Fig.   677. — {Mayo.) 

(a)  Bring  about  i  to  i  1/2  inches  of  the  lowest  part  of  the  parietal  perito- 
neum on  the  left  side  of  the  abdominal  wound  over  to  the  right  side  of  the 
vesicle  wound  and  fix  it  there  by  a  few  catgut  sutures. 


DEFECTS    OF    BLADDER. 


575. 


(b)  Make  a  stab  wound  in  the  bladder  about  3/4  inch  to  the  right  of  the 
lower  end  of  the  vesicle  wound.  Introduce  a  split  rubber  tube  containing 
a  strand  of  gauze  into  the  bladder  and  bring  it  out  through  the  lower  end  of 
the  abdominal  wound.  With  line  catgut  suture  the  parietal  to  the  vesical 
peritoneum  just  external  to  the  stab  wound  in  the  bladder  and  continue  this 
stitching  so  as  to  unite  the  parietal  to  the  vesical  peritoneum  just  above  the  line 
of  the  drainage  tube. 

The  object  of  this  elaborate  method  of  drainage  is  to  avoid  (a)  contamina- 
tion of  the  belly  cavity  with  urine  escaping  along  the  drain;  (b)  contamination 
of  the  line  of  Lembert  sutures. 


Fig.  67Q. 


5.  Close  the  abdominal  wound.  If  drainage  is  not  used,  draw  off  the 
urine  with  a  catheter  as  may  be  necessary;  commonly  the  urine  is  voided  vol- 
untarily.    If  drainage  is  used,  the  dressings  must  be  removed  frequently. 

An  account  of  Young's  method  of  partial  cystectomy  is  given  in  the  section 
on  Excision  of  the  Seminal  Vesicles. 

Rtitkowski's  Operation  for  the  Repair  of  Defects  in  the  Bladder-wall. — Scope 
of  operation:  Rutkowski's  operation  may  be  used  to  close  the  bladder  in  cases 
of  ectopia.  It  also  promises  to  be  useful  in  repairing  the  bladder  after  the 
removal  of  tumors.  In  describing  the  operation  it  will  be  assumed  that  the 
case  is  one  of  tumor. 

The  operation:  1.  Open  the  belly  by  a  4-inch  incision  in  the  middle  line 
near  the  pubis.     Expose  the  bladder. 


576 


OPERATIONS  ON  THE  BLADDER. 


2.  Excise  the  tumor  and  as  much  of  the  vesical  wall  as  may  be  necessary. 

3.  Pull  a  loop  of  ileum  down  towards  the  bladder  and  divide  it  at  two  places 
(x-x,  Fig.  678).  The  distance  between  the  two  lines  of  section  (x-x)  depends 
on  the  size  of  the  defect  in  the  bladder  which  it  is  desired  to  close. 

4.  The  afferent  and  efferent  loops  of  ileum  (a  and  e,  Figs.  678  and  679) 
are  united  by  end-to-end  anastomosis  and  at  once  returned  to  the  abdominal 
cavity. 

5.  The  isolated  segment  of  ileum  (s,  Figs.  678  and  679)  is  split  along  its 
free  border  (i.  e.,  along  the  side  opposite  to  the  mesenteric  attachment).     A 

flap  of  tissue  is  thus  obtained  (s,  Fig.  680)  which  is 
rectangular  in  shape,  covered  on  one  side  by  mucous 
membrane,  on  the  other  by  peritoneum,  and  contains 
non-striated  muscular  fibres.  To  the  middle  of  its 
serous  surface  is  attached  the  mesentery  through  which 
it  is  nourished. 

6.  The  edges  of  the  flap  are  attached  to  the  edges  of 
the  defect  in  the  bladder  by  a  double  layer  of  sutures. 
The  mucous  surface  of  the  flap  faces  the  interior  of  the 
bladder.  The  deep  layer  of  sutures  (catgut)  includes 
the  whole  thickness  of  the  bladder  and  of  the  gut  walls 
except  the  surface  of  the  mucous  membrane.  The 
superficial  layer  (silk)  is  applied  after  the  Lembert 
method.     Continuous  sutures  are  used. 

7.  A  catheter  is  passed  into  the  bladder  per  urethram 
and  is  kept  there. 

8.  The  abdominal  wound  is  closed. 
Mikulicz  has  modified  the  above  operation.     After 

isolating  a  segment  of  ileum  and  uniting  the  afferent 
and  efferent  loops  (Step  4),  he  closes,  by  suture, 
one  end  of  the  isolated  segment  and  sutures  the  other,  or  open  end,  to 
the  abdominal  wound  near  the  bladder.  The  abdominal  wound  is  closed. 
After  a  sufficient  period  of  time  has  elapsed  to  demonstrate  that  the  segment 
of  ileum  is  sufficiently  nourished,  he  proceeds  to  remove  the  vesical  tumor  and 
repair  the  bladder  with  the  segment  of  ileum  obtained  at  the  first  operation. 

Complete  Cystectomy. — Tuffier  ("Revue  de  Chir.,"  April,  1898)  reports 
a  successful  case  of  complete  cystectomy  in  a  man  suffering  from  extensive 
epithelioma  confined  to  the  bladder.  In  his  case  the  operation  was-  com- 
plicated by  a  previous  suprapubic  cystotomy  having  been  practised.  The 
complication  was  overcome  by  packing  the  bladder  with  gauze  and  by  dissecting 
the  fistulous  tract  free  from  the  parietes.  Ample  room  for  work  was  obtained 
by  a  combination  of  the  transverse  and  vertical  incisions  recommended  in 
cystotomy.  The  steps  of  the  operation  were,  briefly,  as  follows:  Exposure 
of  the  anterior  surface  of  the  bladder.  Separation  of  the  anterior  and  lateral 
surfaces  from  the  peritoneum  and  adjacent  structures.     It  is  thus  easy  to  isolate 


Fig.  680. 


CYSTECTOMY.  577 

the  neck  of  the  bladder  and  the  pedicles  containing  the  inferior  vesical  vessels 
and  the  ureters.  Clamp  the  vessels  and  ureters  together  and  cut  between 
the  clamps  and  the  bladder.  Divide  the  neck  of  the  bladder  between  clamps 
and  cauterize  the  opened  urethra.  It^  may  be  well  to  make  the  division  of 
the  vesical  neck  with  the  cautery.  With  forceps  or  clamps  pull  the  bladder 
into  the  abdominal  wound  and  decorticate,  i.  e.,  separate  it  from  its  peritoneal 
covering  under  traction.  Tuffier  succeeded  in  doing  this  without  opening  the 
peritoneal  cavity.  If  the  peritoneum  is  torn,  the  opening  must  be  closed  at 
once  with  sutures.  Having  removed  the  bladder,  turn  to  the  pedicles  con- 
taining the  vesical  vessels  and  ureters.  Isolate  the  ureters  and  tie  the  vessels. 
Pass  a  catheter  into  each  ureter  and  fix  it  to  the  urethra  with  a  stitch.  Ligate 
the  vessels  in  the  urethral  stump. 

In  Tufiier's  case  he  at  once  anastomosed  the  ureters  to  the  rectum,  but  the 
union  evidently  gave  way,  as  the  patient  developed  a  suprapubic  fistula.  If 
the  patient  is  in  poor  condition,  it  is  wise  to  bring  the  ureteral  catheters  out 
through  the  suprapubic  wound  and  leave  any  attempts  at  anastomosis  until 
later.  After  attending  to  hemostasis,  pack  the  cavity  with  gauze  and  partially 
close  the  wound  with  sutures.  Tuffier' s  classical  case  lived  in  comfort  for  seven 
months.  In  the  female,  Pawlik  operated  in  two  stages  with  an  interval  of 
about  three  weeks.     His  operation  may  be  performed  as  follows: 

First  Stage. — Ureter o-vaginal  anastomosis.  Catheterize  the  ureters.  Incise 
the  vagina  over  each  ureter.  Divide  and  bring  the  end  of  each  ureter  into  the 
vagina.  Split  the  lower  end  of  each  ureter  for  about  1/3  inch  and  suture  the 
edges  of  the  split  to  the  vaginal  wound.  Fix  with  stitches  a  catheter  in  each 
ureter. 

Instead  of  practising  any  method  of  ureteral  implantation  Frank  Watson 
advises  permanent  nephrostomy. 

Second  Stage. — Excision  of  the  bladder.  Fill  the  bladder  with  an  emulsion 
of  iodoform.  Through  a  suprapubic  incision  separate  the  bladder  from  its 
surroundings  down  to  the  urethra.  Empty  the  bladder.  Pack  the  suprapubic 
wound  with  gauze.  Make  an  incision  through  the  anterior  wall  of  the  vagina 
at  a  point  opposite  the  internal  urinary  meatus,  pull  the  isolated  bladder 
through  this  incision,  and  divide  it  where  it  joins  the  urethra.  Remove  the 
bladder.  Pass  ureteral  catheters  through  the  urethra  into  the  ureters.  Denude 
and  close  by  sutures  the  vaginal  outlet,  thus  forming  a  urinary  reservoir  drained 
by  the  urethra. 

F.  S.  Watson  recommends  nephrostomy  as  a  preliminary  to  complete 
cystectomy. 

Rovsing  (German  Surg.  Assoc,  1907)  advises  the  removal  of  the  bladder 
as  if  it  was  a  cystic  tumor  without  opening  it. 

Step  I. — Fill  the  bladder  with  a  mild  antiseptic  solution.  Put  the  pafent 
in  Trendelenburg's  posture.  Expose  the  distended  bladder  through  a  curved 
transverse  incision  (convexity  downwards),  near  the  pubis. 

Step  2. — Separate  the  vertex  and  sides  of  the  bladder  from  their  connections. 
37 


578  OPERATIONS    ON   THE   BLADDER. 

While  doing  this  doubly  ligate  and  divide  all  strong  bands  of  tissue  containing 
vessels.  If  possible  separate  the  posterior  wall  from  its  peritoneal  covering. 
If  the  infiltrated  bladder  wall  is  firmly  adherent  to  the  peritoneum,  open  the 
belly  cavity  and  remove  the  bladder  with  its  peritoneal  covering. 

Step  3. — Expose,  doubly  ligate,  and  divide  the  ureters  about  1/2  to  3/4 
inch  from  the  bladder. 

Step  4. — (a)  In  the  female  it  is  easy  to  free  by  blunt  dissection  the  neck 
of  the  bladder  and  about  3/4  inch  of  the  urethra.     Clamp  and  divide  the  urethra. 

{h)  In  the  male  separate  the  base  of  the  bladder  and  the  prostate  from  the 
rectum.  This  leaves  the  bladder  attached  to,  the  body  by  the  membranous 
urethra  alone.  Doubly  clamp  and  divide  the  urethra.  Leave  the  distal 
clamp  in  situ  for  24  hours  to  prevent  bleeding  from  the  cavernous  tissue. 

Step  5. — If  the  peritoneum  has  been  opened,  close  it  with  sutures.  Pack 
the  cavity  with  gauze  which  is  brought  out  through  the  middle  of  the  woimd. 
Unite  the  wounded  recti  muscles.  Close  the  excess  of  wound.  Apply 
dressings. 

Step  6. — Expose  both  ureters  through  a  3-  to  4-inch  incision  on  each  side 
running  obliquely  outwards  and  downwards  from  the  edge  of  the  erector  spinae 
muscles.  The  ureters  can  be  palpated  close  to  the  pelvis  of  the  kidney. 
Fix  the  ureters  v/ith  a  finger  and  with  another  finger  bluntly  dissect  them 
loose  throughout  their  whole  length  and  pull  them  out  of  the  lumbar  wounds. 
Close  the  lumbar  wounds  with  sutures,  leaving  the  ureters  hanging  loosely 
out  of  them.  Pass  a  No.  12  catheter  into  each  ureter  to  prevent  its  compres- 
sion by  the  wound.  Pull  the  exposed  part  of  each  ureter  through  the  per- 
forated finger  of  a  rubber  glove  -to  protect  the  wound.  Apply  dressings.  By 
the  time  the  lumbar  wounds  have  healed  the  excess  of  ureter  has  become 
shrunken  and  necrosed,  and  may  be  removed.  Rovsing  has  performed  the 
above  operation  three  times,  twice  successfully. 

J.  Verhoogen  (Joum.  de  Chir.,  March,  1907;  ref.  Zent.  fiir  Chir.,  1907, 
No.  32)  recommends  the  following  operation: 

(i)   Open  the  abdomen.     Explore  as  to  extent  of  disease,  adhesions,  etc. 

(2)  Expose  the  ureters  where  they  cross  the  vessels  at  the  pelvic  brim. 

(3)  Anastomose  the  right  ureter  to  the  caecum,  the  left  to  the  sigmoid. 
Make  the  anastomoses  valvular,  like  Witzel's  gastrostomy. 

(4)  Excise  the  bladder,  forming  an  anterior  and  posterior  peritoneal  flap. 

(5)  Drain  through  the  vagina,  or,  in  the  male,  through  the  perineum  after 
removing  the  prostate. 

(6)  Close  the  abdominal  wound  entirely. 

Operative  removal  of  benign  neoplasms  gives  good  results;  the  extirpa- 
tion of  malignant  growths  occasionally  does  so. 

Prostatotomy. — The  principle  at  the  base  of  all  operations  for  the  relief 
of  the  troubles  arising  from  enlarged  prostate  is  the  provision  of  drainage  for 
the  most  dependent  portion  of  the  bladder.  Such  drainage  may  be  secured 
by  suprapubic  prostatotomy. 


PROSTATOTOMY. 


579 


Expose  and  open  the  bladder  by  the  vertical  incision.  Explore  the  bladder 
and  recognize  the  nature  of  the  prostatic  obstruction.  Introduce  a  tubular 
speculum  (caisson  or  coffer-dam)  and  engage  the  prostate  in  its  open  end. 
The  use  of  this  is  not  essential.  With  gauze  dry  the  surface  of  the  tissues 
enclosed  in  the  end  of  the  speculum.  Pass  a  thermocautery,  heated  to  a  red 
heat,  through  the  speculum  and  burn  a  groove  or  gutter  from  the  prostatic 
urethra  to  the  vesical  pouch  behind  the  prostate.  This  provides  drainage 
of  the  most  dependent  portion  of  the  bladder.  If  the  lateral  lobes  of  the 
prostate  obstruct  the  urethra,  it  is  well  to  burn 
deep  grooves  or  gutters  in  them  also.  Provide 
suprapubic  drainage  and  partially  close  the 
wound.  This  operation  is  very  similar  in  princi- 
ple to  the  Bottini  operation,  but  it  is  done  under 
guidance  of  the  eye. 

Galvano-caustic  Prostatotomy  {BottinVs  Oper- 
ation).— The  object  of  the  Bottini  operation  is 
to  make  one  or  more  furrows  through  the  ob- 
structing prostate,  thus  lowering  the  vesical  orifice 
of  the  urethra  and  permitting  efficient  drainage  of 
the  bladder. 

The  favorite  instrument  for  division  of  the 
prostate  is  Freudenberg's  modification  of  Bot- 
tini's  galvanocautery  (Fig.  68i).  H.  Young  has 
devised  an  instrument  in  which  various  sized 
blades  can  be  used  ("Jour.  Am.  Med.  Assoc," 
Jan.  II,  1902). 

Da  Costa  thus  describes  the  operation:  "The 
bladder  should  be  emptied,  irrigated,  and  dis- 
tended with  air,  and  the  posterior  urethra  must  be 
anaesthetized  by  instillation  of  cocain  or  eucain. 
The  current  is  tried  to  see  how  many  seconds  it 
requires  to  heat  the  blade  sufficiently.  The  cur- 
rent is  broken,  the  instrument  is  introduced,  the  cooling  current  is  set  in 
motion,  and  one  assistant  watches  this  and  nothing  else.  Turn  on  the  current. 
Wait  the  required  number  of  seconds  for  the  blade  to  become  red  hot  (twelve 
to  fifteen  seconds),  turn  the  screw  at  the  handle,  and  burn  a  groove  in  the 
prostate.  A  groove  should  be  burned  towards  the  rectum,  one  to  the  side, 
and,  if  it  is  thought  desirable,  one  to  the  opposite  side.  No  groove  should 
be  burned  towards  the  pubes.  WTien  a  groove  has  been  burned,  return  the 
blade  into  its  sheath,  increasing  the  current  while  doing  so  in  order  to  keep 
the  blade  from  adhering  to  the  tissue,  and  then  shut  o£f  the  current.  After 
withdrawing  the  instrument  it  is  not  necessary  to  introduce  and  retain  a 
catheter.  The  patient  is  confined  to  bed  only  twenty-four  hours,  there  is 
rarely  bleeding  or  fever,  and  the  results  are  good.     The  scars  contract  and 


Fig.  681.— (Da  Costa.) 


580  OPERATIONS    ON    THE    BLADDER. 

the  gland  atrophies.      During  the  period  of  healing  a  steel  sound  should  be 
passed  from  time  to  time  (Bangs)." 

Chetwood  has  devised  a  short  cautery  which  he  introduces  through  a 
perineal  opening  and  so  escapes  the  grave  danger  of  urethral  injury  mentioned 
on  page  581. 

For  the  indirect  treatment  of  prostatic  hypertrophy  J.  W.  White  has  strongly 
recommended  castration,  and  R.  Harrison  and  Mears,  vasectomy  (division 
or  resection  of  the  vasa  deferentia).  These  operations  are  too  simple  to  re- 
quire description. 

Remarks  on  the  Treatment  of  Prostatic  Hypertrophy. — The  patients 
are  almost  always  aged  in  years  and  still  more  aged  in  physical  condition. 
Unfortunately,  until  recently,  operation  has  been  considered  the  last  resort, 
hence  the  patients  have  been  permitted  to  get  into  a  very  dreadful  condition. 
The  operation  required  for  cure  is  always  one  of  severity,  hence  if  the  patient 
can  be  kept  in  a  fair  state  of  comfort  and  health  by  palliative  treatment,  such 
treatment  is  the  best.  Whenever  hygienic  measures  and  the  proper  use  of 
the  catheter  fail  to  give  relief,  it  is  wrong  to  waste  time;  the  patient  must  be 
given  the  option  of  radical  treatment. 

Castration  or  orchidectomy  is  the  least  efficacious  method  of  treatment 
and  having  a  high  rate  of  mortality  and  of  induced  insanity,  it  has  been  practi- 
cally discarded.  Vasectomy  possesses  any  advantages  which  may  pertain  to 
castration  and  is  much  less  dangerous.  It  has  no  effect  on  fibrous  and  adeno- 
matous enlargement,  but  favorably  influences  congestive  conditions.  It 
seems  to  be  of  use  in  cases  of  "prostatismus"  where  the  symptoms  of  prostatic 
hypertrophy  are  present,  but  there  is  no  residual  urine.  Wassiljew  ("Central- 
blatt  f.  Chir.,"  1903,  No.  26)  thinks  the  benefits  derived  are  due  to  the  resulting 
lowering  of  the  tone  of  the  vesical  sphincter. 

The  main  objects  aimed  at  by  operations  on  the  prostate  are  (i)  removal 
of  the  cause  of  the  obstruction,  (2)  lowering  of  the  vesical  mouth  of  the  urethra 
so  that  the  bladder  may  empty  itself. 

The  most  surgical  means  of  attaining  the  above  objects  is  by  prostatectomy, 
either  suprapubic  or  perineal.  Both  of  these  methods  are  good  in  suitable 
cases.  Where  the  perineum  is  deep  or  where  the  hypertrophy  is  mainly  intra- 
vesical, the  suprapubic  route  is  the  better.  Most  forms  of  hypertrophy  can  be 
removed  by  the  perineal  route,  and  this  route  gives  the  better  drainage.  To- 
day perineal  prostatectomy  is  the  operation  of  choice  with  most  surgeons  in 
America,  while  in  Britain  the  suprapubic  route  seems  the  vogue.  Whichever 
method  is  chosen,  the  operation  is  one  of  severity  and  ought  not  to  be  under- 
taken when  renal  disease  is  present.  Prostatotomy,  whether  accomplished  via 
the  suprapubic  route  by  means  of  a  thermocautery  or  through  the  urethra, 
as  in  the  Bottini  operation,  attains  one  of  the  objects  of  radical  operation  in 
that  it  lowers  the  vesical  orifice  of  the  urethra.  The  suprapubic  method  has 
the  advantage  of  being  done  under  the  guidance  of  the  eye,  with  inexpensive 
instruments,  and  of  requiring  no  special  manual  training.     The  disadvantages 


REMARKS.  581 

are  the  necessary  suprapubic  cystotomy  and  the  fact  that  the  resulting  scar 
in  the  prostate  is  thicker  and  clumsier  than  that  left  by  the  galvanocautery. 
The  Bottini  operation  has  been  thoroughly  tested  by  many  surgeons,  notably 
by  Horwitz  and  Willy  Meyer,  the  latter  having  operated  71  times  on  59  patients 
without  any  reference  to  the  character  of  the  lesion  or  the  presence  of  renal  or 
other  disease.  Out  of  the  59  cases  7  died,  but  the  death  was  the  direct  con- 
sequence of  the  operation  in  but  3. 

The  author  has  seen  one  case  in  which,  owing  to  some  unsuspected  flaw 
in  the  instrument  used,  the  urethra  was  severely  burned,  and  in  part  obliterated, 
while  the  prostate  itself  had  escaped  without  being  cauterized.  The  condi- 
tion of  the  prostate  was  demonstrated  during  a  subsequent  suprapubic  opera- 
tion done  by  J.  Block  to  establish  drainage.  The  original  operator  was  a 
surgeon  of  great  experience  in  this  class  of  work.  Meyer's  experience  is  so 
valuable  that  his  conclusions  may  well  be  quoted  here: 

"i.  The  operations  making  a  direct  attack  upon  the  enlarged  prostate 
gland  are  preferable  to  those  aiming  to  exert  an  indirect  influence. 

"2.  We  have  two  useful  procedures  for  the  direct  treatment  of  the  en- 
larged prostate  gland — i.  e.,  prostatectomy  and  galvano-caustic  prostatotomy 
(Bottini's  operation). 

"3,  In  selecting  the  method  indicated  in  the  given  case  we  must  individu- 
alize and  be  guided  by  anatomical,  pathological,  and  social  conditions. 

''4.  Prostatectomy  is  the  most  radical  and  most  surgical  procedure;  it 
should  be  the  operation  of  choice  whenever  promising  success. 

"5.  Perineal  prostatectomy  offers  advantages  over  the  suprapubir  method, 
since  it  enables  the  operator  to  do  the  operation  under  the  guidance  of  his 
eyes. 

"6. Debilitated  patients  who  seem  unfit  subjects  for  the  more  radical  opera- 
tion should  not  be  at  once  relegated  to  catheter  life,  nor  should,  prostatectomy 
be  performed  in  order  to  'let  them  down  easy.'  They  should  be  advised 
to  have   a   Bottini's   operation   done,   if   possible. 

"7.  Surgeons  should  familiarize  themselves  with  both  methods,  in  order 
to  be  in  a  position  to  do  justice  to  their  patients. 

"8.  It  is  the  duty  of  those  refusing  to  do  Bottini's  operation  under  any 
circumstances,  nevertheless  to  advise  the  latter  in  cases  where  the  patient  asks 
for  more  radical  relief  and  the  operation  with  the  knife  seems  contraindicated. 

"9.  Further  carefully  compiled  statistics  as  to  the  late  results  of  both 
operative  procedures — preferably  in  the  hands  of  one  man — are  desirable 
in  that  they  will  increase  our  knowledge  with  reference  to  the  selection  of  the 
proper  method  in  the  individual  case."  ("Transactions  Am.  Surg.  Assoc," 
vol.  xxi.) 


CHAPTER  XLVII. 
PERINEAL  SECTION. 

PERINEAL  CYSTOTOMY. 

Perineal  cystotomy,  or  the  boutonniere  operation,  is  perhaps  the  simplest 
and  safest  method  of  opening  and  exploring  the  bladder.  As  a  method  of 
exploration  it  is  defective  in  that  it  is  difficult  to  reach  all  parts  of  the  bladder 
with  the  finger,  especially  when  the  perineum  is  deep.  Ocular  inspection 
is  also  impossible.  As  a  therapeutic  agent  it  is  of  great  value  in  providing 
drainage  and  giving  rest  not  merely  to  the  bladder,  but  to  the  urethra;  it  also 
permits  the  removal  of  small  calculi  and  neoplasms  from  the  bladder.  Peri- 
neal cystotomy  is  one  of  the  steps  in  certain  methods  of  perineal  prostatectomy. 
Preparation  of  the  Patient.- — Thoroughly  evacuate  the  large  intestine 
by  means  of  irrigation.  Irrigate  the  bladder  and  partially  fill  it  with  warm 
water  or  boracic  acid  solution.  Shave  the  perineum.  Cleanse 
the  perineum,  scrotum,  penis,  and  hypogastric  region.  Place 
the  patient  in  the  lithotomy  position  with  the  buttocks 
elevated  and  well  over  the  edge  of  the  table. 

The  Operation. — Step  i. — Pass  a  staff,  provided  with  a 
median  groove  on  its  convex  side,  into  the  bladder.  By 
holding  the  handle  of  the  staff  close  to  the  hypogastrium 
force  its  curve  against  the  perineum,  which  is  thus  made 
prominent.  Intrust  the  staff  to  an  assistant,  who  holds  it 
steadily  and  accurately  in  place.  The  surgeon  now  sits 
down,  facing  the  field  of  operation. 

Step  2. — Protect  the  hand  with  a  rubber  glove  and,  per 
rectum,  palpate  the  prostate,  etc.  Having  done  this,  remove 
the  glove.  With  the  fingers  of  the  left  hand  steady  the  skin 
of  the  perineum  and  make  a  median  incision  from  a  point 
posterior  to  the  scroto-perineal  junction  to  within  one  inch  of 
the  anus.  Keeping  strictly  in  the  middle  line,  deepen  the 
incision  until  the  urethral  bulb  is  exposed.  Do  not  injure 
this  structure.  Pull  the  bulb  forwards  in  the  middle  line  and 
continue  the  dissection  behind  it  until  the  staff  can  be  felt  in 
the  membranous  urethra.  Open  the  urethra  on  the  staff,  and  freely  incise  it 
from  the  bulb  to  the  apex  of  the  prostate. 

Step  3. — Guided  by  the  groove  in  the  staff  pass  a  curved  grooved  director 
or  a  Teale's  gorget  (Fig.  682)  into  the  bladder.  Remove  the  staff.  Along 
the  director  or  gorget  push  the  finger  into  the  bladder  with  a  boring  motion. 

582 


Fig.  682. 


PERINEAL   CYSTOTOMY. 


583 


Fig.  683.- — {Es march  and  Kowalzig.) 


This  forcibly  dilates  the  prostatic  urethra.  With  the  finger  explore  for  calculi, 
neoplasm,  enlarged  prostate,  etc.  If  a  small  calculus  is  present,  remove  it  with 
a  lithotomy  forceps  or  scoop.  If  a  small,  benign,  pedunculated  neoplasm 
presents,  remove  it  with  the  finger  or  by  crushing  its  pedicle  with  forceps. 
Be  careful  not  to  drag  forcibly  on  the  tumor.  Sessile  or  large  tumors  are 
better  attacked  through  a  suprapubic  incision. 

Step  4. — Having  finished  the  exploration  or  the  active  operation,  introduce 
a  drainage-tube  approximately  equal  in  size  to  the  exploring  finger.  Wat- 
son's drainage-tube  is  excellent  (Fig.  683).  R.  Harrison  uses  a  large  rubber 
catheter  wath  a  terminal  as  well  as  lateral  eye.  With  one  or  two  points  of 
suture  make  the  perineal  wound  hug  the  tube.  Fix  the  tube  in  place  with  a 
safety-pin  or  tapes.  Test  the  patency 
and  eflaciency  of  the  drain  by  irrigating 
the  bladder  through  it.  The  end  of 
the  tube  should  reach,  but  not  pene- 
trate far  into,  the  bladder. 

Return  the  patient  to  bed,  the 
upper  end  of  which  ought  to  be  ele- 
vated slightly.  The  mattress  ought 
to  be  firm  and  not  sag  under  the 
patient's  weight,   otherwise  drainage 

will  be  poor.  The  perineum  is  covered  by  dressings  kept  in  place  by  a 
T-bandage  through  which  the  drainage-tube  emerges.  It  is  easy  to  attach  to 
the  drain  a  long  rubber  tube  which  conducts  the  urine  to  any  convenient 
receptacle.  After  two  or  three  days  the  drainage-tube  must  be  changed. 
The  time  during  which  drainage  must  be  kept  up  varies  according  to  the 
operation  performed.  After  a  simple  lithotomy  the  tube  should  be  removed 
in  two  or  three  days  and  the  wound  allowed  to  heal.  In  cases  of  cystitis  or 
posterior  urethritis  drainage  ought  to  be  kept  up  until  the  tissues  get  into  a 
healthy  condition. 

If  in  Step  3  forcible  digital  dilatation  fails  to  give  a  sufficiency  of  room, 
median  prosta,totomy  may  be  performed.  Using  the  finger  in  the  prostatic 
urethra  as  a  guide,  introduce  a  probe-pointed  knife  and  with  it  divide  the 
prostate  in  the  middle  line  posteriorly.  Bleeding  may  be  stopped  by  pres- 
sure from  a  snugly  fitting  Watson's  drain  or  by  packing  the  wound  with  gauze 
around  a  stiff  gum-elastic  drainage-tube.  Prostatotomy  performed  as  above 
is  an  integral  part  of  some  of  the  procedures  for  the  removal  of  enlarged  pro- 
static lobes. 

As  the  perineal  operations  for  the  removal  of  vesical  calculi  (lateral  lithot- 
omy. Wood's  operation,  etc.)  are  thoroughly  described  in  every  text-book  on 
general  surgery  ("American  Text-book";  Moullin;  Rose  and  Carless;  Parkes, 
etc.),  they  will  not  be  treated  of  here.  The  same  is  true  of  the  operation  of 
litholapaxy. 


5^4 


PERINEAL    SECTION. 


PERINEAL  PROSTATECTOMY. 

A  very  large  number  of  incisions  have  been  described  by  which  the  pros- 
tate may  be  exposed  in  the  perineum.  When  these  are  analyzed  they  resolve 
themselves  into  two,  each  of  which  may  be  modified  during  the  operation 
according  to  the  dictates  of  common  sense. 


Fig.  684. 


Fig.  68;. 


Figs.  684  and  68^.— (Young.) 


Method  A  :  Median  Incision. — The  earlier  steps  of  this  operation  are 
identical  with  those  of  median  perineal  cystotomy.  When  the  membranous 
urethra  is  opened  and  the  prostatic  urethra  dilated,  pass  into  the  bladder  a 
suitable  tractor,  and  with  it  pull  the  prostate  downwards  into  the  wound. 

Several  efficient  tractors  have  been  devised  for  this  purpose;  the  best  known  are  Parker 
Syms',  provided  with  a  dilatable  rubber  bulb;  Young's  (Figs.  683,  6S4),  having  separable 
metal  blades,  and  A.  H.  Ferguson's.  In  the  absence  of  a  special  instrument  any  good  stout 
metal  sound  answers  the  purpose. 

With  scissors  or  knife  incise  the  fibrous  sheath  of  the  prostate;  insinuate 
the  finger  between  the  sheath  and  the  gland  and  enucleate  the  latter.     Some- 


PROSTATECTOMY.  585 

times  the  prostate  comes  away  in  one  piece,  sometimes  in  two  or  more  frag- 
ments. Most  surgeons  begin  the  enucleation  in  the  left  lobe;  this  is  a  mere 
matter  of  convenience.  "Usually,  but  not  always,  the  floor  of  the  prostatic 
urethra  is  divided  when  the  middle  portion  is  being  taken  out;  but  the  author 
has  had  all  his  specimens  examined  by  the  microscope,  and  it  has  been  shown 
that  no  mucous  membrane  has  been  taken  away"  (except  in  one  case).  (Par- 
ker Syms,  ''Brit.  Med.  Jour.,"  Nov.  8,  1902.)  Drain  the  bladder  by  a  peri- 
neal tube  (No.  36  Fr.)  fastened  to  the  upper  part  of  the  wound.  Pack  the 
wound  cavity  firmly  with  iodoform  gauze.  Attach  a  rubber  tube  to  the  drain 
so  as  to  conduct  the  urine  to  a  suitable  receptacle.  Wash  out  the  bladder 
frequently  through  the  drain.  Change  the  gauze  pack  after  the  lapse  of 
twenty-four  hours,  lessening  the  amount  of  gauze  used.  Encourage  the 
patient  to  move  about  in  bed  and  to  sit  up  at  the  earliest  possible  moment. 
This  is  important.  Remove  the  drain  in  about  one  week.  After  the  drain 
is  removed  wash  out  the  bladder  at  intervals  by  means  of  a  catheter.  Occa- 
sionally introduce  a  sound  to  maintain  the  urethra  patent.  In  operating  in 
much  the  same  manner  as  above  described,  H.  Young  divides  the  prostatic 
capsule  external  to  the  location  of  the  seminal  ducts,  and  believes  he  is  able  to 
remove  a  sufficiency  of  the  gland  without  destroying  these  structures.  That 
portion  of  the  prostate  subjacent  to  the  ejaculatory  ducts  is  not  involved  m 
the  hypertrophic  process  and  hence  can  be  safely  left. 

Another  method  is  as  follows:  Expose  and  open  the  membranous  urethra 
as  above;  guided  by  the  finger  passed  through  the  prostatic  urethra  divide  the 
prostate  posteriorly  in  the  middle  line  with  a  probe-pointed  knife  (median 
prostatotomy).  Seize  the  edge  of  the  divided  capsule  in  forceps,  and  with 
the  finger  separate  the  capsule  from  the  gland  and  shell  out  the  latter  en  masse 
or  in  pieces.  As  the  enucleation  proceeds,  it  is  well  to  make  traction  on  the 
lobes,  which  are  being  removed,  by  means  of  claw-like  sharp  retractors. 
George  Gray,  after  dividing  the  prostate  as  above,  pushes  his  finger  into  the 
bladder,  insinuates  it  between  the  prostate  and  the  vesical  mucosa  and  then 
shells  out  the  enlarged  lobes  from  above  downwards.  Through  the  urethral 
wound  it  is  easy  to  shell  out  the  middle  lobe  if  it  is  enlarged,  and  to  remove 
any  vesical  calculi  which  may  be  present.  In  cases  where  enucleation  with 
the  finger  is  difficult  some  surgeons  extirpate  by  morcel  ement,  cutting  the 
gland  away  piecemeal  with  scissors  or  rongeur  forceps;  when  this  is  done,  it  is 
advised  to  begin  the  extirpation  remote  from,  and  work  towards,  the  urethra. 

Method  B :  Transverse  Incision. — Zuckerkandl  was  probably  the  first 
to  advocate  this  method  of  exposing  the  prostate.  The  whole  operation  has 
been  well  systematized  by  Albarran.  Very  many  operators  have  devised 
various  modifications  in  details,  using  incisions  of  divers  shapes,  H,  Y,  A? 
etc.,  to  increase  the  exposure  of  the  prostate.  Practically,  any  one  of  these 
cuts  give  as  good  results  as  any  other. 

Prepare  the  patient  as  already  described  and  place  him  in  the  lithotomy 
position  with  the  pelvis  well  elevated.     This  posture,  a  combination  of  the 


586  PERINEAL   SECTION. 

Trendelenburg  and  lithotomy  positions,  is  of  very  great  service,  being  almost 
essential.  Introduce  a  sound  or  staff  into  the  bladder  and  entrust  its  handle 
to  an  assistant. 

Step  I. — One  fingerbreadth  in  front  of  the  anus  make  a  slightly  curved 
(concavity  posterior)  transverse  incision  through  the  skin  and  subcutaneous 
tissue,  from  one  ischial  tuberosity  to  the  other. 

Step  2. — -Guided  by  the  sound  in  the  urethra  expose  its  membranous  por- 
tion and  bulb.  Catch  the  tissues  on  each  side  of  the  bulb  with  volsellum  for- 
ceps and  so  pull  the  bulb  upwards  out  of  the  way  and  at  the  same  time  steady 
the  perineum.  Do  not  open  the  urethra.  Introduce  a  finger  of  the  left  hand 
(protected  by  a  rubber  glove)  into  the  rectum,  and  with  the  right  hand  separate 
the  rectum  from  its  anterior  connections — i.  e.,  from  the  prostate.  This  may 
be  done  by  blunt  dissection,  aided  by  an  occasional  cut  with  scissors.  If  the 
surgeon  keeps  close  to  the  prostate,  this  step  is  easy.  The  finger  in  the  rec- 
tum saves  injury  to  that  structure.  Introduce  a  broad,  flat,  long-bladed 
retractor  into  the  wound  and  pull  the  rectum  and  posterior  surface  of  the 
wound  backwards,  exactly  as  the  vagina  is  retracted  in  operations  on  the  cer- 
vix uteri. 

Step  3. — Make  the  assistant  turn  the  beak  of  the  sound  backwards  so  as 
to  lie  behind  the  middle  lobe  of  the  prostate  and  pull  it  down  into  the  wound 
as  mush  as  possible.  Instead  of  a  sound  Young's  (Figs.  684  and  685)  or  Fer- 
guson's prostatic  tractor  may  be  used.     The  prostate  now  lies  exposed. 

Step  4. — Split  the  prostatic  capsule  by  a  transverse  or  vertical  incision  as 
may  be  convenient.  If  it  is  desired  to  save  that  portion  of  prostate  correspond- 
ing to  the  urethral  floor,  make  a  longitudinal  cut  on  each  side  through  the  cap- 
sule. Seize  the  edges  of  the  wound  in  the  capsule  with  forceps  and  with  the 
finger  insinuated  beneath  the  capsule  enucleate  the  gland.  As  the  enuclea- 
ation  proceeds  pull  on  the  part  being  removed  with  claw-shaped  retractors.  If 
the  urethra  is  accidentally  torn,  the  middle  lobe  when  enlarged  can  be  easily 
reached  and  enucleated  with  the  finger.  The  accident  to  the  urethra  does  not 
seem  to  be  of  much  moment.  If  the  urethra  is  not  opened  and  a  projecting 
middle  lobe  is  present,  it  can  be  reached  and  removed  with  the  finger  through 
the  prostatic  wound. 

Step  5. — Partially  close  the  deep  wound  with  sutures.  Introduce  a  drain 
into  the  bladder  and  firmly  pack  the  wound  with  iodoform  gauze. 

It  will  be  seen  that,  except  in  the  matter  of  exposure,  the  operation  by 
transverse  incision  is  almost  identical  with  that  by  median.  Undoubtedly 
by  the  transverse  method  a  much  better  exposure  of  the  field  of  operation  is 
obtained,  at  the  expense  of  a  little  more  trauma,  but  most  of  the  actual  work 
is  done  by  the  finger  unguided  by  the  eye,  hence  the  improved  exposure  is  not 
of  so  much  value  as  might  appear  at  first  glance. 

All  the  operations  here  described  are  carried  out  inside  the  capsule;  extra- 
capsular operations  have  been  devised  and  described,  but  they  occasion  so 
much  shock  and  hemorrhage  that  they  are  unsuited  to  the  extirpation  of  benign 


CANCER    PROSTATE.  587 

neoplasms.  While  none  of  the  methods  described  can  be  truly  named  complete 
prostatectomies,  yet  they  approach  so  nearly  to  completeness  that  they  may  be 
termed  so  for  the  sake  of  convenience  and  to  distinguish  them  from  the  next 
class  of  operations,  which  are  frankly  incomplete.  Rydygier,  Riedel,  and 
others  frequently  expose  the  prostate  by  the  transverse  incision  and  content 
themselves  with  excising  portions  of  the  lateral  lobes,  opening  neither  the  ure- 
thra nor  the  bladder.  The  result  of  taking  away  such  portions  of  the  prostate 
is  that  pressure  is  removed  from  the  prostatic  urethra,  and  as  the  wounds 
heal  and  contract,  the  urethral  lumen  is  widened.  The  method  is  less  severe 
than  the  more  complete  operations  and  has  given  good  results  even  in  cases 
in  which  the  middle  lobe  has  been  enlarged.  Of  course,  the  operation  is 
meant  primarily  for  cases  of  hypertrophy  of  the  lateral  lobes  and  it  has  a  dis- 
tinct field  of  usefulness. 

Radical  Prostatectomy  for  Cancer. — Young  has  described  a  method 
of  removing  the  prostate  for  cancer  ("Johns  Hopkins  Bulletin,"  Oct.,  1905; 
"Annals  Surg.,"  Dec,  1909)  which  he  carried  out  in  six  cases.  One  of  the 
patients  was  alive  and  well  four  and  a  half  years  and  another  six  months  after 
the  operation.  The  operation  is  only  suited  to  cases  in  which  the  disease 
is  well  limited  to  the  prostate  or  at  least  does  not  extend  more  than  a  short  dis- 
tance beneath  the  trigone. 

The  Operation. — Steps  i,  2  and  3. — Place  the  patient  in  the  exaggerated 
lithotomy  position.  Expose  the  membranous  urethra  and  prostate  by 
an  inverted  V-incision.  Proceed  as  in  prostatectomy  by  the  transverse  inci- 
sion (Method  B,  Steps  i,  2,  3,  p.  585)  until  the  prostatic  tractor  is  put  in  place 
and  the  posterior  surface  of  the  prostate  has  been  exposed,  largely  by  blunt 
dissection.  If  there  is  any  doubt  as  to  diagnosis,  incise  the  capsule  and 
remove  a  segment  of  gland  for  immediate  microscopic  examination. 

Step  4. — Free  the  lateral  adhesions  of  the  prostate  and  also  the  seminal 
vesicles  as  much  as  possible  by  blunt  dissection.  Divide  the  membranous 
urethra  in  front  of  the  tractor. 

Step  5. — Depress  the  handle  of  the  tractor  markedly  and  divide  the  pubo- 
prostatic ligaments  close  to  the  prostate  after  pushing  away  the  anterior  plexus 
of  veins.  Hemorrhage  must  be  controlled  by  clamps  and  by  a  gauze  pack 
held  tightly  against  the  posterior  surface  of  the  pubes  and  the  triangular  liga- 
ment by  means  of  a  retractor.  At  this  time  the  seminal  vesicles  may  be 
further  freed. 

Step  6. — Pull  the  prostate  as  far  as  possible  out  of  the  wound,  thus  exposing 
the  anterior  wall  of  the  bladder.  Open  the  bladder  by  a  transverse  incision 
close  to  its  junction  with  the  prostate.  Enlarge  the  incision  until  the  trigone  is 
well  exposed.  (Fig.  686,  Young.)  With  a  scalpel  continue  the  transverse 
cut  in  the  bladder  across  the  trigone,  leaving  the  upper  angles  of  the  trigone 
intact  and  the  ureters  uninjured.  By  blunt  dissection  through  the  wound  in 
the  bladder  complete  the  exposure  of  the  seminal  vesicles,  pick  up  the  vasa 
deferentia    and    divide    them    as   high    as   possible.      Remember    that    the 


588 


PERINEAL    SECTION. 


Fig.  086. — (Youn^,  A)inals  of  Surg.) 


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FXG.  687. — {Yoimg,  Annals  of  Surg 


PROSTATOTOMY.  589 

vasadeferentia  pass  around  the  lower  end  of  the  ureters  which  must  not  be 
injured. 

Step  7. — Separate  the  deep  attachments  of  the  seminal  vesicles  controlling 
the  resulting  bleeding  by  clamps  and  ligatures.  Remove  the  prostate,  seminal 
vesicles,  and  about  5  cm.  of  the  vasa  deferentia  in  one  piece. 

Step  8. — Pull  the  anterior  wall  of  the  bladder  down  and  form  an  anasto- 
mosis between  the  anterior  part  of  the  bladder  wound  and  the  divided  mem- 
branous urethra,  using  catgut  for  sutures.  (Fig.  687,  Young.)  Close  the  rest 
of  the  vesical  wound  by  catgut  sutures.  Introduce  through  the  penis  a  reten- 
tion catheter. 

Step  g. — Approximate  the  levator  ani  muscles  with  catgut  sutures.  Par- 
tially close  the  skin  wound  after  providing  for  drainage. 

INFRAPUBIC  PROSTATOTOMY  AND  CYSTOTOMY. 

The  prostate  and  lower  part  of  the  bladder  may  be  exposed  immediately 
under  the  pubic  arch.  This  route  avoids  the  neighborhood  of  the  anus,  with 
its  ever  present  infection,  while  it  gives  more  direct  access  to  the  prostate  and 
better  drainage  than  does  the  suprapubic  route.  If  the  patient  is  feeble,  the 
operation  may  be  done  in  two  sittings,  the  first  consisting  of  the  exposure  of 
the  prostate,  the  second  of  the  prostatotomy  or  prostatectomy.  (L.  Heusner, 
" Centralblatt  f.  Chir.,"  1904,  p.  217.) 

Step  I. — Make  a  curved  incision  through  the  skin  along  the  lower  margin 
of  the  pubis  and  its  descending  rami. 

Step  2. — Divide  the  insertion  of  the  suspensory  ligament  of  the  penis,  the 
corpora  cavernosa;  the  ischio-cavernosus  muscle,  the  triangular  ligament, 
and  part  of  the  insertion  of  the  adductor  muscles.  With  a  chisel  or  rongeur 
forceps  cut  away  about  half  of  the  symphysis  pubis  and  of  the  descending 
rami.  Separate  the  prostate  from  the  posterior  surface  of  the  pubes.  When 
this  is  done,  it  is  easy  to  pull  the  prostate  downwards  and  expose  its  whole 
anterior  surface.  Bleeding  from  the  plexus  of  veins  anterior  to  the  prostate 
is  liable  to  be  considerable.  If  this  cannot  be  sufi&ciently  controlled  to  permit 
of  further  progress,  or  if,  as  in  Heusner' s  case,  the  patient  is  too  weak,  it  is  easy 
to  pack  the  wound  and  resume  the  operation  after  the  lapse  of  a  few  days. 

Step  3. — Pass  a  sound  into  the  bladder  per  urethram.  Using  the  sound  as  a 
guide,  split  the  prostatic  urethra  through  its  whole  extent  along  its  anterior 
or  ventral  surface.     This  exposes  the  prostate  exactly  as  in  a  postmortem. 

Step  4. — Remove  all  obstructing  lobes  exactly  as  is  done  when  other  methods 
of  exposure  are  employed.  If  it  is  desired  to  open  the  bladder  instead  of  the 
prostate,  this  is  easily  accomplished  by  the  removal  of  more  bone  from  the 
pubis.  The  operation  is,  however,  much  more  suitable  for  prostatic  than  for 
vesicular  disease. 

Step  5. — Close  the  wound  in  the  prostate  with  a  few  catgut  sutures.  Pro- 
vide for  drainage.     Close  the  skin-wound. 


CHAPTER  XLVIII. 
URETHRAL   STRICTURE. 

Meatotomy. — As  a  preliminary  to  the  introduction  of  urethral  sounds  it 
is  often  necessary  to  enlarge  the  meatus. 

Introduce  a  probe-pointed  knife  into  the  urethra  for  a  distance  of  about  3/4 
inch,  i.  e.,  to  a  point  immediately  behind  the  meatal  narrowing.  Cut  in  the 
middle  line  below  but  do  not  cut  completely  through  to  the  external  surface, 
otherwise  a  hypospadias  will  be  produced.  The  after-treatment  consists  in 
keeping  the  wound  open  by  passing  a  sound  or  a  glass  rod  at  frequent  intervals. 

Internal  Urethrotomy. — Preparation  of  Patient. — Sometimes  it  is  wise  to 
prepare  the  patient  by  administering  urotropin  or  its  equivalent  for  a  day  or 
two  before  operation.  Immediately  before  operating  wash  the  penis  and 
especially  the  glans  with  soap  and  water,  cover  the  thighs  and  abdomen  with 
sterile  towels,  irrigate  the  urethra  (and  if  possible,  the  bladder)  with  a  mild 
antiseptic  solution  or  with  warm  salt  solution.  Inject  into  the  urethra  a  drachm 
or  two  of  sterile  olive  oil  and  immediately  proceed  to  operate. 

There  are  two  types  of  operation:  (A)  in  which  the  stricture  is  divided 
from  before  backwards;  (B)  in  which  the  division  is  from  behind  forwards. 
The  latter  method  presupposes  that  the  stricture  is  not  a  narrow  one  or  that 
it  has  been  already  dilated  sufficiently  to  admit  the  passage  of  the  urethrotome. 
Of  the  two  types  of  operation  there  are  many  varieties  but  only  the  typical 
procedures  will  be  described  here.  The  number  and  varieties  of  urethro- 
tomes are  legion.  Their  description  would  take  up  much  space  and  serve  no 
useful  purpose. 

A.  Division  of  the  Stricture  from  Before  Backwards. — Prepare  the  patient 
as  above.  Determine,  if  possible,  the  site  and  extent  of  the  stricture  or 
strictures  by  means  of  a  bougie  a  houle.  Introduce  through  the  stricture  a 
soft  filiform  bougie  the  proximal  end  of  which  is  fitted  with  a  screw.  Screw  the 
distal  end  of  a  Maisonneuve  urethrotome  (Fig.  688)  to  the  filiform  guide. 
Push  the  urethrotome  along  the  urethra,  the  knife  blade  being  in  contact  with 
the  middle  of  the  roof  of  the  urethra.  The  knife  blade  being  blunt  at  its 
apex  cannot  cut  the  normal  urethra,  but  its  distal  edge  being  sharp  cuts  the 
stricture  when  it  comes  against  it.  Having  divided  one  stricture,  remove 
the  urethrotome  and  explore  the  whole  urethra  so  as  to  find  if  other  stenoses 
are  present.     The  urethra  should  now  admit  a  full-sized  sound. 

B.  Otis^  Operation:  Division  of  the  Stricture  from  Behind  Forwards. — 
Preparation  and  exploration  of  the  urethra  as  already  described.  Introduce 
an  Otis'  urethrotome  (Fig.  6S9)  through  the  stricture.     By  means  of  the  screw 

590 


URETHROTOMY. 


591 


at  the  proximal  end  separate  the  blades  of  the  instrument  until  the  tissues  of 
the  stricture  are  put  on  the  stretch  but  not  torn.  Up  to  this  time  a  knife  blade 
lies  concealed  at  the  distal  end  of  the  urethrotome.  By  using  the  proper 
mechanism,  make  the  knife  blade  protrude  and  cut  through  the  stricture  in 
the  middle  line  above.  Sheath  the  knife  blade  again.  Complete  the  dila- 
tation of  the  stricture  by  separating  the  blades  of  the  urethrotome  until  the 


Fig.  688. 


Fig.  689. 


urethra  is  large  enough  to  admit  a  full-sized  sound.     Remove  the  urethrotome. 
Explore  for  the  presence  of  other  strictures. 

Complications  and  Dangers  of  Internal  Urethrotomy.— i.  Hemorrhage. 
By  cutting  in  the  middle  line  above,  the  least  vascular  region  is  incised. 
The  stricture  itself  is  sclerosed,  non-vascular  fibrous  tissue,  hence  severe  bleed- 
ing is  not  common.  When  serious  bleeding  arises  it  may  be  controlled  by 
the  passage  of  a  full-sized  catheter  and  if  necessary  by  exercising  pressure 
from  the  outside  on  the  urethra  which  is  now  supported  by  the  catheter. 


592 


URETHRAL   STRICTURE, 


2.  Urethral  Fever. — This  is  usually  a  form  of  septic  intoxication  due  to 
the  absorption  through  the  urethrotomy  wound  of  septic  products  already 
existing  in  the  urethra  or  being  discharged  with  the  urine.  Septicemia  or 
pyemia  are  rare.  Methods  of  avoiding  urethral  fever:  (a)  Preliminary  exhibi- 
tion of  substances  {e.  g.,  urotropin)  calculated  to  improve  the  condition  of  the 
urine,  (b)  Rigid  asepsis,  (c)  Konig  advises  to  irrigate  the  bladder  with  a 
mild  antiseptic  solution  as  soon  as  the  operation  is  completed  and  to  leave  in 
the  bladder  a  few  ounces  of  the  solution.  This  dilutes  and  favorably  affects 
the  urine  so  that  noxious  substances  are  not  absorbed  from  it  when  it  is  next 
voided. 

Irrigation  of  the  urethra  during  convalescence  is  rarely  necessary. 

After-treatment. — The  patient  ought  to  be  kept  in  bed  for  a  few  days.  If 
there  is  retention  of  urine  a  soft  rubber  catheter  must  be  passed.  Catheteri- 
zation may  often  be  avoided  by  applying  moist  heat  to  the  perineum  and 
hypogastrium  or  by  placing  the  patient  in  a  hot  bath  with  instructions  to  uri- 
nate in  the  water,  if  he  can. 

After  a  lapse  of  five  to  seven  days  pass  a  full-sized  sound  into  the  bladder. 
Before  this  can  be  done  successfully  it  may  be  necessary  to  pass  a  number  of 
smaller  instruments  of  increasing  size.  Repeat  the  passage  of  sounds  at 
intervals  of  two  or  three  days.  The  daily  passage  of  sounds  irritates  and  is 
useless.  The  interval  is  to  be  gradually  increased  until  a  cure  or  practical 
cure  is  obtained. 

External  Urethrotomy. — Prepare  the  patient  as  for  internal  urethrotomy. 
In  addition  scrub  and  shave  the  perineum.     Clean  the  scrotum  and  the  adja- 


FiG.  690. 


cent  portions  of  the  buttocks  and  thighs.  Explore  the  urethra  and  locate 
the  stricture.     Put  the  patient  in  the  lithotomy  position. 

A.  Operation  with,  a  Guide. — Various  instruments  may  be  used  as  guides. 
The  best  is  probably  the  Syme's  staff  (Fig.  690).  Filiform  whalebone  bougies 
serve  the  purpose  well  and  are  more  commonly  obtainable. 

Step  I. — Pass  the  guide  into  the  bladder.  If  Syme's  instrument  is  used 
the  thin  portion  passes  through  the  stricture,  the  thick  portion  serves  as  a  guide 
to  the  urethra  on  the  meatal  side  of  the  stricture.  If  the  whalebone  filiform 
is  used,  pass  alongside  it  or  looped  on  it  (like  Gouley's  sounds)  a  large  metal 
sound  down  to  the  face  of  the  stricture.  Let  an  assistant  hold  the  sound 
steadily  in  the  middle  line  of  the  body  and  make  its  point  press  towards  the 
skin  of  the  perineum.     Retract  the  scrotum  upwards. 

Step  2. — Palpate  the  perineum  and  feel  the  point  of  the  sound.     In    the 


•  URETHROTOMY.  593 

middle  line  make  an  incision  down  to  the  point  of  the  sound.  This  opens  the 
urethra  immediately  anterior  to  the  stricture.  Retract  the  edges  of  the  ure- 
thral wound  with  sharp  hooks,  fine  volsella,  or  with  a  couple  of  fine  sutures 
introduced  for  the  purpose.  Withdraw  the  metal  sound.  If  Syme's  guide 
is  used  leave  it  in  situ. 

Step  3. — If  possible  pass  a  fine  grooved  director  along  the  guide  and  with 
a  knife  split  the-  stricture  completely.  If  it  is  impossible  to  introduce  a  grooved 
director  cut  down  upon  the  guide  from -in  front  backwards  until  the  whole 
stricture  is  divided.  It  is  convenient  at  this  stage  to  pass  through  the  perineal 
wound  a  probe-pointed  Teale's  gorget  (Fig.  691)  into  the  urethra  posterior 
to  the  stricture.  The  gorget  acts  as  a  guide  to  the  full-sized  sound  or  catheter 
which  must  now  be  passed  through  the  urethra  into  the  bladder.  The  use  of 
the  gorget  is  not  necessary'. 


Fig.  691. 

There  are  many  modifications  of  the  above  operation,  most  of  them  requir- 
ing special  instruments.  For  a  description  of  such  see  treatises  on  genito- 
urinary surger)'.     The  operation  as  described  has  served  the  author  well. 

B.  Operation  Without  a  Guide. — ^Prepare  as  described  above. 

Step  I. — Pass  a  metal  sound  down  to  the  face  of  the  stricture.  Have  it 
held  by  an  assistant  accurately  and  steadily  in  the  middle  line. 

Step  2. — Incise  the  perineum,  expose  the  sound,  and  retract  the  edges  of 
the  urethral  wound  as  in  the  preceding  operation.     Remove  the  sound. 

Step  3.- — Examine  carefully  the  face  of  the  stricture  with  the  eye  and  a 
fine  probe  for  an  opening  through  it.  Remember  that  the  opening  may  be 
in  any  position  on  the  face  of  the  stricture.  The  search  may  be  aided  by 
making  a  little  pressure  on  the  hypogastrium,  and  so  forcing  some  urine  along 
the  urethra  and  out  through  the  stricture,  where  its  point  of  emergence  should 
be  noted.  If  it  is  possible  to  find  the  passage  through  the  stricture  and  to 
introduce  a  probe  the  operation  becomes  identical  with  that  in  which  a  guide 
is  used.     If  the  introduction  of  a  probe  is  impossible  proceed  as  follows: 

Incise  the  stricture  longitudinally  exactly  in  the  middle  line  until  the  healthy 
urethra  is  reached  posterior  to  the  stricture.  If  this  is  not  promptly  accom- 
plished, do  not  waste  time  and  lacerate  the  tissues  by  making  more  incisions 
in  the  stricture  tissues,  but  boldly  endeavor  to  incise  the  urethra  posterior  to 
the  stricture,  always  cutting  in  the  middle  line.  When  the  urethra  is  opened 
at  this  point  it  is  easy  to  cut  through  the  stricture  and  pass  a  sound  from  the 
38 


594  URETHRAL   STRICTURE. 

meatus  past  the  perineal  wound  into  the  bladder.  If  the  posterior  urethra 
is  not  easily  found  during  the  above  procedure  do  not  spend  much  time  looking 
for  it,  as  such  a  search  may  do  much  damage.  Open  the  bladder  above  the 
pubis  and  pass  a  sound  through  the  bladder  to  the  perineum  (retrograde  cathe- 
terization). The  point  of  this  sound  acts  as  a  guide  and  makes  incision  of 
the  urethra  easy.  The  value  of  abstention  from  much  burrowing  in  the 
perineum  and  of  retrograde  catheterization  is  insisted  on,  as  the  author  has 
seen  much  damage  result  from  the  former  and  no  harm  from  the  latter 
procedure. 

AJter-treatment. — Immediately  after  the  operation  irrigate  the  bladder. 
Stop  all  hemorrhage.     Two  methods  of  attending  to  urination  are  now  possible: 

{a)  Apply  a  gauze  pad  to  the  perineal  wound  and  permit  the  urine  to  escape 
either  through  the  meatus  or  through  the  perineum,  as  it  pleases.  In  one  of 
the  author's  cases  hardly  a  drop  of  urine  escaped  through  the  wound. 

{h)  Introduce  a  catheter  (Jacob's  self-retaining  catheter  is  best)  through 
the  wound  into  the  bladder  and  keep  it  there.  It  is  easy  to  connect  the 
catheter  to  a  long  tube  and  so  drain  the  urine  into  some  convenient  receptacle. 

Keep  the  perineal  wound  clean  and  frequently  change  the  dressings. 
Some  simple  antiseptic  ointment  applied  to  the  surrounding  skin  gives  comfort 
and  lessens  scalding.  After  the  lapse  of  five  to  eight  days  pass  a  sound  through 
the  meatus  into  the  bladder.  This  is  usually  difficult.  The  writer  has  more 
than  once  found  a  spur  in  the  depth  of  the  perineal  wound  which  rendered  the 
passage  of  the  sound  impossible.  Division  of  the  spur  was  all  that  was  neces- 
sary. The  spur  itself  was  undoubtedly  the  result  of  insufficient  division  of 
the  stricture  at  the  primary  operation. 

Repeat  the  passage  of  the  sounds  at  constantly  increasing  intervals  until  a 
cure  is  effected.  The  perineal  wound  heals  rapidly  unless  some  strictures 
exist  in  the  urethra  anterior  to  it. 

Urethrectomy :  Excision  of  Stricture. — Complete  urethrectomy  is  com- 
paratively rarely  indicated;  it  means  excision  of  the  whole  circumference  of  the 
urethra.  Incomplete  urethrectomy  is  the  usual  operation;  in  it  a  portion  of 
the  dorsal  wall  of  the  urethra  is  preserved.  The  preservation  of  even  a  small 
strand  of  dorsal  wall  is  of  much  importance,  as  it  aids  marvelously  in  securing 
apposition  and  acts  as  a  guide  in  catheterization. 

Perineal  Urethrectomy. — Step  i. — Prepare  the  patient  and  open  the  ure- 
thra as  in  external  urethrotomy. 

Step  2. — If  not  already  done,  pass  a  sound  or  probe  through  the  stricture. 
With  forceps,  knife,  and  scissors  carefully  and  thoroughly  remove  every  par- 
ticle of  the  contracted  and  deforming  scar  tissue  from  the  under  and  lateral 
side  of  the  urethra,  but  preserve,  if  at  all  possible,  a  portion  of  the  upper  wall 
of  the  urethra.     It  is  necessary  to  remove  all  the  diseased  tissue. 

Step  3. — Restoration  of  the  Urethra. — (a)  Introduce  throught  he  penis  to 
the  bladder  a  retention  catheter.  Make  an  end-to-end  union  over  the  catheter 
of  the  divided  urethra  by  fine,  interrupted  catgut  sutures  which  do  not  pene- 


URETHRECTOMY. 


595 


trate  the  mucosa.  To  avoid  stenosis  it  is  necessary  to  incise  longitudinally 
the  floor  of  each  segment  to  be  united  and  convert  the  longitudinal  into  trans- 
verse wounds  when  suturing  (Fig.  692,  AA',  BB').  Be  sure  that  each  stitch 
has  a  firm  hold.  Either  close  the  superficial  perineal  wound  with  sutures 
or  permit  it  to  heal  by  granulation. 

(b)  Hartmann  usually  introduces  a  retention  catheter  and  over  it  closes 
the  wound  with  fine  catgut  sutures  which  do  not  penetrate 

the  mucosa,   but  grasp  all  the  perineal  tissues  except 
the  skin.     The  skin  wound  he  leaves  open  (Fig.  693). 

Methods  a  and  b  are  only  useful  when  the  separation 
of  the  two  segments  of  urethra  is  not  more  than  about 
I  1/2  inches  (3  to  4  centimeters). 

(c)  When  the  urethral  defect  is  very  great,  treat  as 
after  external  urethrotomy.  When  all  the  diseased 
tissue  has  been  excised  the  wound  heals  readily  and 
rapidly,  leaving  a  scar  which  is  much  softer  and  less 
liable  to  contract  disastrously  than  if  diseased  tissue 
had  been  left  (Hartmann). 

After-treatment. — Remove  the  retention  catheter  on 
the  eighth  day.    On  the  twelfth  day  begin  passing  sounds. 
Penile  Urethrectomy. — Apply  an  elastic  constrictor 
to  the  root  of  the  penis. 

Step  I. — Make  a  longitudinal  median  incision  to  expose  the  stricture. 
Excise  the  whole  cicatricial  node,  even,  when  requisite,  removing  part  of  the 
corpora  cavernosa. 

Step  2. — Suture  the  urethra  with  fine  catgut  sutures  which  do  not  penetrate 
the  mucosa.  Suture  the  cavernous  and  spongy  bodies  according  to  necessity. 
Remove  the  elastic  constrictor  so  as  to  observe  and  control  hemorrhage. 
Close  the  skin  wound. 

Step  3. — Open  the  perineal  urethra  and  through  this  wound  introduce  a 
self-retaining  catheter  to  keep  the  penile  urethra  from 
being  irritated  by  the  passage  of  urine. 

Remarks. — Urethrectomy  gives  better  results  than 
external  urethrotomy,  but  it  rarely  results  in  a  radical 
cure.  Subsequent  passage  of  sounds  remains  necessary 
in  most  cases. 

Rupture  of  the  Urethra.— Operative  treatment  of 
urethral  rupture  varies  greatly  according  as  the  case  is 
seen  early  or  late,  when  infection  and  necrosis  have  taken  place.  Practically 
every  case  of  urethral  rupture  demands  prompt  operation.  It  is  rarely 
possible  to  introduce  a  catheter  beyond  the  site  of  rupture;  even  when  this 
is  possible  perineal  section  ought  to  be  performed  to  evacuate  effused  blood 
and  provide  free  drainage. 

I.  Early  Operations. — Lithotomy  position.     Clean  the   perineum    and   its 


596  URETHRAL    STRICTURE. 

surroundings.  Pass  a  sound  through  the  penis  down  to  the  site  of  rupture. 
Expose  the  injured  urethra  exactly  as  in  external  urethrotomy.  Find  the 
opening  into  the  posterior  segment  of  the  urethra.  This  may  be  easy  but  is 
often  extremely  difficult.  If,  after  reasonable  search  in  the  well  retracted 
w^ound  aided  by  reflected  light  and  the  use  of  probes,  etc.,  the  posterior  urethra 
cannot  be  found,  it  is  usually  advised  to  incise  in  the  median  line  further  back, 
and  so  enter  the  intact  portion  of  the  posterior  urethra  and,  by  means  of  a  probe 
passed  from  behind  forwards,  find  the  desired  orifice.  To  the  author  it  seems 
much  better,  under  the  above  circumstances,  to  open  the  bladder  above  the 
pubis,  practise  retrograde  catheterization,  and  subsequently  drain  or  siphon 
the  urine  through  the  suprapubic  wound. 

When  the  site  of  injury  has  been  well  exposed,  blood  clots  evacuated, 
injured  shreds  of  tissue  removed,  the  urethral  wound  may  be  (a)  closed  as 
after  urethrectomy  or  (b)  drained  as  after  external  urethrotomy. 

If,  when  the  patient  is  seen,  he  is  in  very  poor  condition  from  shock,  do  not 
immediately  operate  as  above.  Either  evacuate  the  urine  from  the  bladder 
by  suprapubic  aspiration  and  await  reaction,  or,  guided  by  a  sound  passed 
into  the  urethra,  cut  down  to  and  freely  open  the  urethra  at  the  site  of  injury, 
and  making  no  search  for  the  posterior  opening  into  the  urethra,  trust  to 
simple  drainage.     Simple  drainage  has  stood  the  writer  in  good  stead. 

II.  Late  Operation. — Late  operation,  i.  e.,  operation  after  there  is  much 
infiltration  of  urine,  distinct  infection  and  necrosis  of  tissues,  resolves  itself 
into  the  treatment  of  the  urinary  infiltration  and  phlegmonous  inflammation. 

The  operation  is  identical  whether  the  trouble  is  due  to  a  neglected  trau- 
matic rupture  or  to  neglected  stricture,  etc. 

A  sound  passed  per  urethram  to  the  site  of  injury  may  be  an  aid;  it  is  not  a 
necessity,  as  the  aim  of  the  surgeon  at  this  time  is  not  to  definitely  open  the 
urethra  but  to  open  the  collections  of  pus,  urine,  etc.,  in  the  tissues.  The  urine 
will  escape  sufficiently  through  the  opened  abscesses.  In  the  cases  under  con- 
sideration (only  a  few  hours  may  have  elapsed  since  the  accident)  the  scrotum, 
penis,  and  perineum  are  usually  very  much  swollen. 

Lejars  writes:  "Don't  try  to  catheterize.  Don't  waste  time  by  making 
haphazard  and  insufficient  incisions  in  the  most  oedematous  zones;  at  once 
attack  the  perineum." 

The  Operation. — Lithotomy  position.  Cleanse  and  shave  the  perineum 
and  surroundings.  Retract  the  scrotum  upwards.  Make  a  median  perineal 
incision  about  i  1/2  to  2  inches  long.  The  posterior  end  of  the  incision  must 
be  at  least  one  fingerbreadth  from  the  anus  to  avoid  injury  to  the  sphincter. 
Continue  deepening  the  incision  until  urine  and  pus  escape  freely.  On  account 
of  the  swelling,  it  may  be  necessary  to  penetrate  2  inches  or  more.  Always 
keep  to  the  middle  line  and  persist  until  the  fluid  is  found.  Lejars  makes  the 
above  incision  with  the  thermocautery;  the  author  has  always  used  the  knife. 

When  the  urine  and  pus  are  found,  explore  with  the  finger  and  open  up 
subsidiary  cavities.     If  necessary  make  counter  openings.     Puncture  or  incise 


RUPTURE    OF    URETHRA.  597 

freely  all  greatly  swollen  regions,  e.  g.,  on  the  scrotum  and  penis.  Apply 
plentiful  moist  dressings.  When  the  swelling  and  inflammation  subsides, 
incisions  which  at  first  seemed  enormous  become  almost  invisible.  The  whole 
operation  consists  in  making  (a)  free  primary  perineal  incision,  (b)  free  sub- 
sidiary incisions  wherever  necessary.  It  is  better  to  make  too  many  and  too 
free  incisions  than  too  few  and  two  small. 

Late  Operation  in  an  Unusual  Form  of  Urinary  Infiltration. — WTien  the 
urine  escapes  behind  the  triangular  ligament,  the  territories  infiltrated  are 
the  pelvis,  the  ischiorectal  fossae,  and  the  hypogastrium.  The  penis,  scrotum, 
and  perineum  are  unaffected.  The  operative  treatment  required  consists  in 
free  median  incision  above  the  pubis,  in  free  opening  of  the  ischiorectal  fossae, 
and  in  drainage  of  the  bladder. 


CHAPTER  XLIX. 
EPISPADIAS. 

Epispadias  is  closely  allied  to  hypospadias,  and  when  there  is  curvature 
of  the  organ  from  fibrous  tissue  contraction  this  must  be  corrected  in  the 
same  fashion  as  in  hypospadias. 

Thiersch's  operation  is  performed  in  several  stages: 

I.  Construction  of  urethra  in  the  glans  penis.  Parallel  to  the  groove  in 
the  glans  make  two  incisions,  as  shown  in  Fig.  694,  a  and  b.  Lay  a  glass 
or  metal  rod  along  the  groove,  and  with  it  depress  the  groove,  at  the  same 
time  sliding  the  lateral  portions  of  the  glans  (mobilized  by  the  two  incisions) 
over  the  rod,  and  unite  their  raw  surfaces  by  quill  sutures  (Fig.  694,  c).  WTien 
the  balanic  urethra  is  safely  and  firmly  established  and  the  wounds  healed, 
proceed    to 


Fig.  694. —  (Esmarch  and  Kowalzig.) 

II.  Construct  the  penile  urethra.  Make  the  skin-flap  a  (Fig.  695)  along 
the  whole  length  of  the  urethral  groove  and  with  its  base  next  the  groove. 
Make  the  similar  skin-flap  h,  with  its  base  remote  from  the  urethral  groove. 
Turn  the  flap  a  over  so  that  it  covers,  and  has  its  skin  surface  next  to,  the  groove. 
With  a  few  points  of  suture  fix  the  cut  edge  of  flap  a  to  the  under  or  raw  sur- 
face of  flap  b,  near  its  base  (Fig.  695).  Pull  flap  b  over  flap  a  and  suture 
its  free  edge  to  the  raw  surface  on  the  penis  left  by  the  elevation  of  flap  a  (Fig. 
696).  In  tracing  out  the  two  flaps  a  and  b,  the  former  is  made  narrower 
than  the  latter. 

III.  K  small  opening  still  exists  between  the  new-formed  tubes  in  the 
penis  and  glans.  In  epispadias  the  incomplete  but  usually  redundant  prepuce 
hangs  below  the  glans.  Make  a  transverse  hole  through  the  prepuce  near 
its  base  (Fig.  696,  c,  c)  and  push  the  glans  through  it.  The  prepuce  now 
lies  on  the  top  of  the  penis,  and  by  suturing  the  edges  of  the  wound  in  it  to 
the  vivified  edges  of  the  urethral  defect,  the  latter  can  be  closed  (Fig.  697). 

IV.  A  defect  remains  at  the  base  of  the  penis.  To  close  this,  vivify 
the  edges  of  the  defect,  and  forming  a  flap  (Fig.  698,  a'),  turn  it  over  and  suture 
its  edges  to  the  edges  of  the  defect,  thus  providing  an  epidermal  lining  to  the 

598 


EPISPADIAS. 


599 


portion  of  urethra  covered.  Another  skin-flap  (Fig.  698,  a)  is  reflected  and 
made  to  cover  the  exposed  raw  surface  of  flap  a'.  This  procedure  is  objection- 
able in  that  the  skin-flap  a  will  assuredly  develop  hair  and  cause  trouble. 
It  is  far  better  to  cover  the  opening  with  a  single  flap — raw  surface  inwards — 


Fig.  695.  Fig.  696. 

Figs.  695  and  696. — {Esmarch  and  Kowalzig.) 


Fig.  697. 
Figs.  697  and 


Fig.  698. 

-{Esmarch  and  Kowalzig.) 


as  Cheyne  recommends.     The  contraction  which  subsequently  occurs  is  far 
less  objectionable  than  the  growth  of  hair  inseparable  from  Thiersch's  plan. 
As  is  stated  in  the  chapter  on  "Hypospadias,"  all  operations  which  pro- 
vide an  epidermal  lining  for  the  new  urethra  from  skin  in  which  hair  is  liable 


6oo 


EPISPADIAS. 


to  grow  are  very  objectionable,  hence  Rosenberger's  ingenious  and  simple 
operation  is  to  be  condemned  and  will  not  be  described. 

The  Van  Hook-Mayo  operation  for  hypospadias  is  entirely  suitable  in 
cases  of  epispadias. 

Cantwell's  Operation. — This  most  ingenious  and  logical  operation 
("Annals  Surg.,"  Dec,  1895)  seems  to  have  been  unaccountably  overlooked. 
The  author  is  indebted  to  Wetherill  for  drawing  his  attention  to  it. 

Step  I. — Open  the  bladder  through  the  perineum  and  introduce  a  Watson 
drainage-tube. 

Step  2. — Recognize  the  line  of  junction  between  the  mucosa  of  the  gutter- 
like urethra  and  the  skin  of  the  penis.  On  each  side  of  the  urethral  groove 
make  a  longitudinal  incision  along  these  lines  of  muco-cutaneous  junction, 


Fig.  699. 

from  the  symphysis  to  the  extremity  of  the  glans.  (Fig.  699,  a.)  Unite  the 
incisions  above  the  opening  into  the  bladder.  The  incisions  penetrate  to  but 
must  not  injure  the  corpora  cavernosa.  Separate  the  urethra,  as  a  flap,  from 
its  bed  and  hold  it  aside.     (Fig.  699,  b.) 

Step  3. — With  sharp  and  blunt  dissection  separate  the  one  corpus  cavernosum 
from  the  other  until  the  skin  on  the  lower  surface  of  the  penis,  is  reached. 
(Fig.  699,  c.) 

Step  4. — Place  the  mobilized  urethra  in  the  bottom  of  the  long  penile  wound 
and   fix  it   there   by   a   couple   of   sutures. 

Step  5. — Lay  a  sound  or  a  glass  rod  along  the  urethra  (which  is  a  mere 
groove)  and  suture  the  urethra  over  the  rod  so  as  to  form  a  tube.  Remove 
the   rod. 

Step  6. — Bring  the  corpora  cavernosa  together  over  the  urethra  and  close 
the  wound.     (Fig.  699,  d.)     The  urethra  now  occupies  its  normal  site. 


CHAPTER  XLIX. 
HYPOSPADIAS. 

In  hypospadias,  owing  to  an  error  in  development,  the  urethral  floor  is  defec- 
tive. The  defect  may  be  slight  or  great,  and  according  to  its  degree  the 
deformity  is  of  the  following  types:  (i)  Balanic,  i.  e.,  confined  to  the  glans, 
the  urethral  meatus  being  immediately  behind,  while  the  balanic  urethra  is 
absent  or  represented  by  a  mere  groove  or  gutter.  (2)  Penile  type.  The 
urethral  opening  is  situated  at  any  point  between  the  scrotum  and  the  glans; 
the  anterior  urethra  is  absent  or  represented  by  a  mere  groove.  (3)  Perineo- 
scrotal type.  The  urethral  opening  is  in  the  perineum  and  the  scrotum  is 
divided. 

In  any  form  of  hypospadias  except  the  mildest  the  defective  penis  is  curved 
downwards,  and  held  in  a  position  of  chordee  by  dense  fibrous  tissue  bands 
which  exist  oji  its  lower  surface.  These  bands  are  an  important  element 
in  treatment,  as  no  operation  can  be  of  any  value  which  does  not  correct  the 
curvature.  Duplay  corrects  the  chordee  deformity  by  making  transverse 
incisions  through  the  fibrous  bands.  The  incisions  may  be  subcutaneous 
or  open,  according  as  the  skin  is  contracted  or  loose.  When  the  incisions  are 
open,  they  may  be  covered  by  skin-grafts  or  rendered  longitudinal  by  means 
of  sutures.  Bleeding  is  not  great,  as  any  tissues  divided  are  sclerosed.  Some 
surgeons  excise  much  of  the  scar  tissue.  The  straightening  of  the  penis  must 
be  thorough,  if  requisite  several  incisions  being  employed.  While  healing 
is  progressing  the  corrected  position  may  be  retained  by  strapping  the  penis 
to  the  belly-wall.  (In  cases  of  epispadias  a  splint  is  requisite.)  Several 
weeks   may   be   spent  in  obtaining   a   straight  organ. 

Wliere  the  deformity  is  of  the  balanic  type,  the  foreskin  may  be  complete 
or  may  be  divided;  in  the  latter  case  it  is  usually  redundant  and  hangs  over 
the  glans  as  a  hood.  Operation  is  required  because  of  narrowness  of  the 
urethral  opening  and  because  of  the  great  inconvenience  arising  from  the 
impossibility  of  directing  the  stream  in  urinating.  If  the  urethra  is  represented 
by  a  groove  on  the  under  aspect  of  the  glans,  it  may  be  converted  into  a  tube 
by  freshening  its  edges  and  uniting  them  over  a  glass  rod,  or  by  an  operation 
identical  with  that  of  Thiersch.     (See  "Epispadias.") 

In  a  case  in  which  the  above  operation  had  been  unsuccessful  the  author 
obtained  a  good  result  from  utilizing  the  foreskin  in  the  following  way: 
Vivify  one  edge  of  the  urethral  groove  (x  Y,  Fig.  700).  Divide  the  foreskin 
along  the  line  x  y.  Suture  the  raw  edge  of  the  foreskin  wound  Y  p,  to  the 
freshened  edge  of  the  urethral  groove  x  y,  (Fig.  701).     Wait  until  union  has 

601 


6o2 


HYPOSPADIAS. 


taken  place.  Divide  the  foreskin  along  the  line  a  b,  Fig.  701.  Freshen 
the  corresponding  edge  of  the  urethral  groove.  Unite  with  sutures  the  raw- 
edge  of  the  foreskin  to  the  edge  of  the  urethral  groove.  The  result  is  shown 
in   Fig.    702. 


Fig.  700. 


Fig.  701. 


Fig.  702. 


Beckys  Operation. — Beck's  operation  is  suitable,  not  only  in  cases  where 
the  urethra  is  defective  at  the  glans,  but  where  it  is  defective  for  a  short  dis- 
tance  behind   it. 


Fig.  703. 


Figs.  703  and  704. — {Beck.) 


Fig.  704. 


Dissect  the  distal  end  of  the  complete  urethra  free  from  its  surroundings 
for  a  suitable  distance  (Figs.  703,  704,  705,  706).  This  mobilizes  the  tube 
so  that  it  can  be  pulled  forwards  and  sutured  to  the  vivified  urethral  groove 
on  the  under  surface  of  the  glans.     Where  there  is  no  urethral  groove  on 


HYPOSPADIAS. 


603 


the  glans,  some  surgeons  perforate  the  glans  from  before  backwards  or  from 
above  downwards  and  backwards  (Ochsner)  and  pull  the  mobilized  end  of 
the  urethra  through  the  tunnel,  suturing  it  there.  When  the  defect  belongs 
to  the  penile  or  scroto-perineal  type,  other  operations  are  required. 

Duplay's  Operation. — First  sitting:  Straightening  of  the  penis. 

Second  sitting:  Correction  of  the  deformity  in  the  glans,  as  in  Thiersch's 
operation  for  epispadias. 

Third  sitting:  Establish  perineal  drainage,  by  the  boutonniere  operation. 
C.  H.  Mayo  advises  the  introduction  of  a  Jacobs'  self-retaining  female  catheter 
through   the   perineal    wound.     Correct   the   urethral    deformity   as   follows: 


Fig.  705. 

Figs.  705  and  706. — (Beck.) 


Fig.  706. 


Make  a  longitudinal  incision  (a,  b,  Fig.  707)  parallel  to  and  about  3/8  inch 
distant  from  the  edge  of  the  urethral  groove.  At  each  end  of  this  incision 
make  a  transverse  incision  beginning  at  the  edge  of  the  urethral  groove  and 
ending  at  a  point  well  external  to  the  longitudinal  cut.  These  cuts  outline 
two  flaps,  one  of  which  (x,  Fig.  707)  has  its  base  at  the  urethral  groove;  the 
other,  p,  has  its  base  towards  the  side  of  the  penis.  Reflect  these  flaps.  On 
the  opposite  side  of  the  urethral  groove  duplicate  the  above  incisions  and  form 
the  flaps  Y  and  q.  Pass  a  rod  through  the  lately  formed  urethra  of  the  glans 
and  permit  it  to  lie  in  the  urethral  groove.  Reflect  the  flaps  x,  Y,  on  to  the  rod 
(Fig.  708)  so  that  their  epidermal  surfaces  next  to  the  rod  and  their  raw  surfaces 
are  exposed.     These  two  flaps  should  not  be  so  wide  that  their  edges  meet 


6o4 


HYPOSPADIAS. 


over  the  rod.  Approximate  the  flaps  p  and  Q  by  means  of  the  suture  s  s^ 
(Fig.  708).  The  skin  is  so  loosely  attached  to  the  penis  that  it  is  easy  to  slide 
the  flaps  p  and  q  inwards  so  that  their  raw  surfaces  are  partly  in  contact  with 
those  of  X  and  y  and  partly  with  one  another.  The  sutures,  of  silkworm- 
gut  or  silver  wire,  should  be  fastened  to  perforated  lead  plates  which  extend 
the  whole  length  of  the  wound  on  each  side  of  it  (quill 
sutures).  The  lead  plates  prevent  the  sutures  cutting  out 
and  assist  in  keeping  the  parts  at  rest. 

The  above  operation  is  a  modification  of  Duplay's 
operation  for  epispadias.  After  the  penile  urethra  is 
completely  formed  there  is  still  a  hiatus  between  it  and 
the  urethra  leading  from  the  bladder.  This  hiatus  is 
closed  in  the  manner  described  in  the  chapter  on  "Epi- 
spadias." 

Thiersch's  operation  for  epispadias  is  also  suitable 
in   hypospadias. 

Many  ingenious  operations  have  been  devised  by 
which  a  new  urethra  is  formed  from  the  skin  of  the 
scrotum  (Rosenberger,  Wood,  etc.).  All  these  are  objec- 
tionable in  that  hair  will  grow  on  the  skin  used  in  the 
making  of  the  new  urethra  and  cause  an  infinity  of 
trouble. 

Nove-Josserand  has  devised  a  most  ingenious  method 
of  operating,  but  whether  it  will  prove  of  much  value  or 
not  is  still  doubtful.  The  operation  is  performed  as  fol- 
lows: Divide  the  skin  transversely  immediately  in  front 
of  the  urethral  opening  (a,  Fig.  709).  From  this  cut  make  a  subcutaneous 
tunnel,  by  means  of  a  trocar,  to  the  point  of  the  penis.  Cut  a  large  Thiersch 
skin-graft  and  roll  it  around  a  glass  rod,  fixing  it  to  the  rod  by  means  of  a 
ligature  at  each  end  (Fig.  7 10).  Pass  the  rod  covered  with  the  graft  through  the 
newly-made  tunnel  in  the  penis.  Apply  dressings.  After  eight  days  remove 
the  rod.  It  will  be  wise  to  drain  the  bladder  by  means  of  a  Jacobs'  self-re- 
taining cathether  introduced  through  a  perineal  incision,  and  thus  avoid  con- 
tamination of  the  wound  with  urine.  For  a  few 
months  after  recovery  pass  sounds  at  intervals, 
as  there  is  a  tendency  to  contraction.  Various 
materials  have  been  used  to  take  the  place  of 
skin  in  the  Nove-Josserand  operation.  Schmieden 
has  implanted  a  ureter  obtained  during  an  oper- 
ation for  hydronephrosis;  experimentally  an  artery  has  been  utilized. 
Tanton  published  in  1909  an  experiment  in  which  he  replaced  the  urethra 
by  implanting  a  segment  of  vein.  Tanton,  Tufiier,  Stettiner,  have  applied 
this  experiment  to  man  and  have  been  successful  ("Journal  de  Chir.," 
June,  1 9 10). 


Fig.  707. 


Fig.  708. 


HYPOSPADIAS. 


605 


The  operation  for  the  posterior  penile  type  of  hypospadias  is  performed 
in  two  stages  at  an  interval  of  from  two  to  five  weeks. 

First  Stage. — (a)  Correct  the  chordee  as  already  described. 

(b)  Provide  for  suprapubic  drainage  through  as  small  an  incision  as 
possible  and  without  suturing  the  bladder  to  the  skin.  Keep  the  bladder 
clean  by  frequent  irrigations  \\dth  a  mild  antiseptic  solution.  Change  the 
drainage  tube  at  intervals  as  it  becomes  encrusted  with  urinary  salts. 

Second  Stage.— (a.)  Excise  a  segment  of  the  internal  saphenous  vein.  The 
segment  ought  to  be  about  50  per  cent,  longer  than  the  portion  of  urethra  to 
be  constructed,  as  the  excised  vein  shrinks  greatly.  Wash  the  vein  and  pre- 
serve it  in  warm  salt  solution. 


Fig.    709.  Fig.  710. 

Figs.   709  .and  710. — (.Mcmod  and  Vanverts.) 


(h)  Introduce  a  sound  into  the  hypospadiac  opening  and  mobilize  the  urethra 
around  the  sound  by  careful  dissection. 

(c)  Make  a  tunnel  as  in  the  Xove-Josserand  operation  from  the  glans 
through  the  penis  to  the  incision  around  the  mobilized  urethral  opening. 
'(d)  With  vaseline  lubricate  a  bougie  and  pass  it  through  the  segment  of 
vein  obtained  in  step  a. 

(e)  Pass  the  bougie,  with  the  vein  on  it,  through  the  tunnel  made  in  the 
penis  and  make  the  point  of  the  bougie  go  into  the  mobilized  urethral  orifice. 

(f)  Suture  the  open  end  of  the  vein  to  the  open  end  of  the  mobilized 
urethral  orifice  by  means  of  mattress  sutures    which  cause  eversion.     (To 


6o6 


HYPOSPADIAS. 


the  author  this  seems  bad  practice,  as  it  must  bring  the  inner  surface  of  the 
vein  into  apposition  with  the  inner  or  epithelial  surface  of  the  urethra,,  a  con- 
dition which  must  be  inimical  to  healing.) 

(g)  Having  anastomosed  the  implanted  vein  to  the  urethral  orifice,  close 
the  wound  on  the  under  surface  of  the  penis  (or  perineum)  with  one  or  two 
rows  of  sutures.  Place  a  very  small  drain  under  the  skin  for  twenty-four 
or  forty-eight  hours. 

(h)  Unite  the  other  end  of  the  vein  to  the  edges  of  the  wound  in  the  glans. 
Remove  the  bougie. 

After-treatment. — Remove  the  drain  after  twenty-four  to  forty-eight  hours 
After  the  lapse  of  iive  or  six  days  inject,  most  gently,  enough  sterile  olive  oil 
to  slightly  distend  the  new  urethra.     Repeat  the  injection  daily.     After  about 


Vu 


Fig 


Figs.  711  and  712. — {C.  H.  Mayo.) 


two  weeks  begin  the  use  of  sounds,  but  use  them  gently  and  at  intervals  of 
two  to  three  days.  Only  after  the  lapse  of  about  one  month  is  it  proper  to 
pass  sounds  large  enough  to  really  dilate  the  new  urethra.  When  the  new- 
urethra  has  become  thoroughly  acclimatized  introduce  a  catheter  and  leave 
it  in  place  until  the  hypogastric  fistula  has  closed. 

Tanton's  operation  promises  well,  but  late  results  have  not  yet  been  re- 
ported. Van  Hook  ("Annals  of  Surgery,"  April,  1896)  and  C.  H.  Mayo 
("Journ.  Am.  Med.  Assoc,"  April,  1901)  have  devised  very  similar  operations 
which  may  be  performed  as  follows: 

"The  prepuce  is  extended  as  for  circumcision  and  two  incisions  are  made, 
about  I  inch  apart,  extending  from  its  border  to  its  attachment  at  the  penile 
cervix;  the  prepuce  is  unfolded,  forming  a  loop  of  thin  skin  about  21/2  inches 
in  length.  Should  this  not  be  considered  sufficient  to  reach  from  its  attach- 
ment to  the  hypospadiac  opening,  the  two  incisions  are  extended  back  along 
the  dorsum  of  the  penis  until  suflScient  tissue  is  obtained,  where  the  two  inci- 
sions are  connected  by  a  transverse  one,  and  the  flap  of  skin  lifted  but  left 


HYPOSPADIAS.  607 

attached  to  the  cervix  by  the  mner  surface.  Several  sutures  now  close  the 
lateral  integument  over  the  denuded  area  (Fig.  711).  The  pedunculated 
flap  of  prepuce  is  constructed  into  a  tube  with  its  skin  or  outer  surface  inside, 
by  means  of  a  number  of  catgut  sutures.  The  penis  is  tunneled  by  means 
of  a  narrow  bistoury  or  medium  trocar  and  cannula,  through  the  glans,  above 
its  groove,  along  the  penis  to  a  point  beneath  the  hypospadiac  opening,  when 
it  is  made  to  emerge  at  one  side  of,  but  close  to,  the  urethra;  the  tube  of  prepuce 
is  drawn  through  the  tunnel  and  sutured  where  it  enters  the  glans  and  also 
where  it  emerges  (Fig.  712).     At  the  end  of  ten  days  the  pedicle  of  the  flap 


'^^S 

ivEgni 

>*^i^ 

/mt'  '■|f  '  »^wW 

^■i 

S^ 

^/     '^^ 

IP 

W 

sf     i 

,^^k3i 

wirfi^ 

--  /Vv                    v] 

^§ 

W(m"      '^ 

i-.-  ^^^SB^P^ 

7/fj 

fWk% 

^ 

IP:    1 

Fig.  713.— (C.  H.  Mayo.) 

is  cut  through  close  to  the  new  meatus.  The  second  operation,  made  at  a 
later  period,  consists  of  a  perineal  opening  into  the  urethra  and  insertion  of 
a  Jacobs'  self-retaining  female  catheter;  this  is  the  least  irritating  form  of 
catheter  and  can  be  left  as  long  as  needed — usually  from  five  to  eight  days. 
An  incision  at  the  termination  of  the  two  urethras  now  admits  of  accurate 
coaptation  by  sutures,  or  the  normal  urethra  may  be  mobilized  (Beck  method) 
to  a  sufficient  extent  to  admit  of  its  insertion  into  the  new  urethra,  where 
it  is  held  by  sutures  and  the  external  parts  closed  over  this  (Fig.  713).  Oc- 
casionally a  little  urine  escapes  into  the  urethra,  and  the  entire  canal  is  best 
drained  by  passing  several  strands  of  silkworm-gut  or  horse-hair  through 
the  urethra  and  out  alongside  the  catheter  in  the  perineal  opening." 


CHAPTER  LI. 

AMPUTATION  OF  PENIS. 

Partial  Amputation.* — I.  Amputation  of  Glans  and  Part  of  Penis. — Step 
I. — Apply  an  elastic  constrictor  to  the  root  of  the  penis.  Make  an  incision 
through  the  skin  completely  round  the  penis  and  at  least  3/4  inch  distant 
from  the  disease.  Retract  or  reflect  the  skin  upwards  for  about  1/2  inch'. 
(The  natural  elasticity  of  the  skin  will  produce  enough  retraction  without  the 
aid  of  the  surgeon.) 

Step  2. — Expose  and  ligate  the  dorsal  artery  and  veins  of  the  penis. 
Step  3.- — ^Divide  the  corpora  cavernosa  transversely.     At  a  point  nearly 
1/2    inch   farther   forward   divide    the   urethra   transversely. 

Step  4.— With  catgut  suture  the  ends  of  the  corpora  cavernosa  (Fig.  714). 
This   assures   hemostasis. 

Step  5. — In  the  middle  line  below  make  a  short  incision  through  the  skin. 
Make  a  corresponding  cut  in  the  urethra  (Fig.  714  and  715).     Suture  the 

split  urethra  to  the  skin.     This  splitting 
and  suturing  prevents  contraction. 

Nicoll,   most    sensibly,    modifies   the 
operation  as  follows:       Step  (a)      Make 
an   incision   over   each  inguinal  region. 
Unite  these  incisions  in  the  middle  line 
P    at  the  root  of  the  penis  and  from  their 
'^    point   of  union  make  an  incision  along 
^    the  mid-dorsal  line  of  the  penis  to  the 
■^    place  chosen  for  amputation.     Step  {b) 
Beginning    at    each    groin    dissect    free, 
from  the  outside  inwards,  the  lymphatics 
Fig.  714.  Fig.  715.        of    the    groins    and    then,    from    above 

downwards,  those  of  the  dorsum  of 
the  penis.  Remove  all  these  lymphatics  in  one  piece.  After  this  proceed  to 
amputate. 

II.     Complete  A  mpiitation.    (Gould's  method.) — Place  in  lithotomy  position. 
Step   I. — Split  the  scrotum  completely  along  the  raphe,   and  thoroughly 
expose  the  corpus  spongiosum. 

Step  2. — Pass  a  sound  through  the  urethra  to  the  triangular  ligament. 
Separate  the  corpus  spongiosum  from  the  corpora  cavernosa.  Remove  the 
sound.  Divide  the  corpus  spongiosum  and  isolate  the  urethra  as  far  as  the 
triangular   ligament. 

608 


AMPUTATION   OF   PENIS.  609 

Step  3. — Continue  the  scrotal  incision  through  the  skin  around  the  root 
of  the  penis.  Divide  the  suspensory  ligament.  Separate  the  crura  from  the 
pubic  bones.  The  only  vessels  requiring  ligation  are  those  of  the  crura. 
This  completes  the  amputation. 

Step  4. — Make  a  short  split  in  the  urethral  stump.  Suture  the  edges 
of  the  split  urethra  to  the  posterior  portion  of  the  scrotal  wound. 

Step  5. — Suture  the  skin  wound  after  providing  for  drainage. 

Remarks. — ^Very  good  results  have  been  obtained  by  the  above  operations 
with  or  without  removal  of  the  inguinal  lymph  glands.  Cancer  of  the  penis 
is  usually  of  comparatively  slow  growth.  Recurrence  usually  is  in  the  lymph 
glands.  Butlin  advises  removal  of  the  inguinal  glands  as  a  secondary  opera- 
tion. If  the  urethra  is  split  and  united  to  the  skin  as  described,  difficulties 
in  micturition  are  largely  avoided.  Amputation  at  the  junction  of  the  middle 
and  distal  third  or  at  the  middle  of  the  penis  does  not  necessarily  destroy 
the  power  of  coitus  and  begetting  (Butlin).  The  danger  of  the  operations 
described  is  not  much  over  2  per  cent. 

III.  Emasculation. — If  the  disease  is  extensive  or  of  rapid  growth  a  much 
more  serious  and  radical  operation  is  proper.  This  operation  is  based  on 
a  study  of  the  penile  lymphatics. 

The  lymphatics  of  the  penile  skin  and  of  the  prepuce  anastomose  freely 
and  drain  into  the  superficial  lymphatic  glands  on  both  sides.  The  lymphatics 
of  the  glans  pass  up  along  with  the  dorsal  veins  of  the  penis  to  a  few  lymphatic 
glands  which  lie  in  front  of  the  pubis;  from  this  point  they  take  two  courses: 
(a)  to  deeply  located  glands  lying  on  the  inner  side  of  the  femoral  vein,  (b) 
along  the  inguinal   canal   imder  the   spermatic   cord. 

From  the  above  (see  "Traite  d'Anatomie  Humaine,"  Poirier  et  Charpy, 
Tome  II)  it  is  evident  that  it  is  safe  to  make  a  difference  in  the  extent  of  opera- 
tion according  as  the  glans  is  involved  or  not.  If  the  glans  is  not  affected 
a  theoretically  complete  operation  means  removal  ^ 

of  the  superficial  lymph  glands  from  both  inguinal  P^^^^^^^^f;' 

regions,  removal  of  the  penis  and  removal  of  the  V^^^^^^^^^^^^^ 

lymph  channels  between  the  penis  and  the  lymph      /^Cl^^^?^^^^^' 
glands.     If  the  glans  is  also  involved  a  theoret-      ^^^^^^^^'"' 
ically  complete  operation  means  removal  of  the  P^^       g 

above  structures  plus  the  deep  inguinal  glands  to 

the  inner  side  of  the  femoral  vein  and  plus  the  lymphatics  under  the  cord  in 
the  inguinal  canal  and  plus  the  prepubic  glands.  Technically  it  may  be 
possible  to  do  all  this  and  preserve  the  scrotum  and  testicles,  practically  it 
seems  better  to  remove  these  organs  also.  In  the  operation  to  be  described 
it  is  assumed  that  the  glans  is  affected.  The  method  is  one  which  the  writer 
elaborated  for  his  own  use,  but  which  is,  of  course,  not  original. 

Step  I. — After  the  usual  cleansing  and  shaving  of  the  whole  operative 
territory,  clean  the  diseased  parts  as  well  as  possible,  swabbing  them  with 
Harrington's  solution  or  liquid  carbolic  or  even  touching  them  with  the  cautery. 
39 


6io 


AMPUTATION    OF   PENIS. 


Apply  dressings  to  the  disease  and  cover  them  with  oiled  silk.  Suture  the 
dressings  or  coverings  to  the  skin  of  the  penis.  These  precautions  are  taken 
to  prevent  infection.     Once  more  clean  the  operative  territory. 

Step  2. — Make  an  incision  over  the  inguinal  canal  parallel  to  Poupart's 
ligament.  Open  the  canal  by  splitting  the  aponeurosis  of  the  external  oblique. 
Lift  up  and  mobilize  the  spermatic  cord  and  all  the  fat  surrounding  it.     Doubly 


Fig.  717. 


ligate  and  divide  these  structures  as  high  up  as  possible  (Fig.  716).  Obliter- 
ate the  now  empty  inguinal  canal  by  suturing  the  wound  in  the  aponeurosis 
(Fig.  717). 

Step  3. — Through  the  original  wound,  supplemented  if  necessary  by  a 
subsidiary  incision,  expose  Scarpa's  triangle  above  the  saphenous  opening 
(Fig.  717).  Beginning  at  the  lower  and  outer  sides  of  the  exposed  area,  dissect 
the  superficial  inguinal  glands,  along  with  the  fat  surrounding  them,  upwards 
and  inwards  towards  the  pubis. 

Step  4. — Expose  and  remove  the  deep  inguinal  glands.  These  vary  in 
number  from  i  to  3.  When  three  are  present  one  lies  just  below  the  long 
saphenous  vein,  one  in  the  femoral  canal,  and  one  in  the  femoral  ring.  All 
are  to  the  inner  side  of  the  femoral  vein. 


AMPUTATION    OF    PENIS. 


6ll 


Step  5. — Repeat  steps  2,  3,  4  on  the  opposite  side.  Incise  the  skin  immedi- 
ately above  the  root  of  the  penis,  uniting  by  this  cut  the  two  incisions  over 
the  inguinal  canals.  On  each  side  of  the  root  of  the  penis  make  an  incision 
downwards  over  the  root  of  the  scrotum.  Dissect  downwards  the  fat  in  front 
of  the  pubis,  until  the  crura  of  the  penis  are  exposed.  Divide  the  suspensory 
ligament.  The  results  of  the  work  accomplished  up  to  this  point  are:  (a) 
All  the  lymphatic  glands  and  tissue  which  may  presumably  be  affected  are 
dissected  up  and  now  hang,  along  with  the  spermatic  cords  and  the  prepubic 
fat,  attached  to  the  penis  and  scrotum  (Fig.  718).  The  inguinal  canals  which 
were  opened  have  been  closed.  Any  wound  which  may  have  been  made 
to  expose  Scarpa's  triangle  may  now  be  closed. 


Fig.  718. 


Step  6. — Working  from  above  downwards,  separate  the  crura  of  the  penis 
from  the  pubic  bones.  Complete  the  incision  through  the  scrotum  below 
and  behind.  Expose  and  mobilize  the  corpus  spongiosum  at  the  root  of 
the  scrotum.  Divide  the  corpus  spongiosum  and  urethra.  A  few  catgut 
sutures  through  the  cavernous  tissue  prevent  hemorrhage.  It  is  now  easy 
to  remove,  in  one  piece,  the  penis,  scrotum  with  its  contents,  superficial  inguinal 
glands,  and  the  lymphatics  of  the  inguinal  canal.  (The  deep  inguinal  glands 
were  removed  separately.) 

Step  7. — Make  a  slight  split  in  the  urethral  stump  and  suture  the  edges 
of  the  urethral  wound  to  the  most  posterior  part  of  the  cutaneous  wound. 
Close  the  extensive  skin  wound  with  sutures  after  providing,  where  necessary, 
for  drainage. 


6l2 


AMPUTATION    OF   PENIS. 


N.B. — When  removing  the  scrotum  it  is  well  to  leave  enough  of  its  pos- 
terior w^all  to  be  brought  forward  and  upward  and  united  to  the  edge  of  the 
wound  across  the  pubis.  When  this  is  done  the  urethra  can  be  brought  through 
a  button-hole  cut  in  the  base  of  the  scrotal  flap  (Fig.  719).     When  removing 


Fig.  719. 
I,  I.  Inguinal  wounds.    SF.  Scrotal  flap. 


U.  Urethral  opening. 


the  scrotum  v.  Dittel  retained  a  portion  of  the  posterior  scrotal  skin  which 
he  wrapped  around  the  stump  of  the  corpus  spongiosum  (left  long  for  this  pur- 
pose). The  effect  of  this  detail  was  the  formation  of  a  sort  of  "spout"  which 
enabled  the  patient  to  urinate  without  taking  down  his  trousers. 


CHAPTER   LII. 
CIRCUMCISION. 

There  are  several  methods  of  performing  circumcision;  most  of  these  are 
merely  modifications  of  the  following: 

Classical  Method. — Feel  and  locate  the  corona  or  groove  behmd  the  glans 
penis,  the  prepuce  being  in  normal  position  is  not  retracted.  Place  a  clamp 
(the  handles  of  a  long  scissors  form  an  efiicient  clamp)  on  the  skin  correspond- 
ing to  the  corona.  Gently  tighten  the  clamp  so  as  to  hold  the  skin  between 
its  blades  and  yet  permit  the  glans  to  be  pushed  back  behind  it.  Push  back 
the  glans  so  that  it  lies  in  safety  behind  the  clamp.  Tighten  the  grasp  of 
the  clamp.  The  whole  skin  and  part  of  the  mucous  membrane  of  the  prepuce 
now  lie  in  front  of  the  clamp;  the  glans  and  part  of  the  mucous  membrane 
of  the  foreskin  lie  behind  it. 


Fig.  720. — {Veau.) 


Fig.  721. — {Veau.) 


Remove,  with  a  knife,  all  the  structures  in  front  of  the  clamp.  Remove  the 
clamp.  The  skin  retracts  to  the  root  of  the  penis,  the  glans  is  covered  by  a  tube 
of  mucous  membrane  having  a  raw  and  bleeding  external  surface.  Cut  away 
(Fig.  720)  all  except  about  1/3  inch  of  the  mucous  membrane.  If  thefrenum 
is  short  and  pulls  the  glans  downwards  and  backwards,  divide  that  structure 
transversely  and  in  suturing  convert  the  transverse  into  a  longitudinal  wound, 
thus  lengthening  the  frenum  (Fig.  721).  Pull  the  skin  forward,  and  suture 
it  to  the  mucous  membrane.  Apply  vaseline  or  some  ointment  to  the  woimd 
and  protect  with  a  small  piece  of  gauze.     No  elaborate  dressings  are  of  any 

613 


6i4 


CIRCUMCISION. 


value.  Warn  the  patient  or  his  mother  that  the  penis  will  become  swollen 
and  discolored;  this  warning  may  prevent  the  operator  being  summoned  to 
treat  non-existent  hemorrhage.  Serious  post-operative  hemorrhage  is  rare. 
Before  operating,  especially  if  cocaine  is  used,  it  is  well  to  apply  an  elastic 
constrictor  round  the  root  of  the  penis. 

Atypical  Operation. — With  scissors  or  knife  split  the  prepuce  in  the  mid- 
dorsal  line  to  the  corona.     Beginning  at  the  angle  of  the  wound  trim  away 

as  much  of  the  redundant  tissues  as  may  seem 
necessary.  Stitch  the  skin  to  the  mucous  membrane. 
Many  surgeons  omit  the  removal  of  any  tissue 
after  splitting,  but  this,  at  least  temporarily,  leaves 
the  foreskin  hanging  below  the  glans  like  an  ele- 
phant's ear  and  causes  much  annoyance  to  the 
sensitively  inclined. 

The  adhesions  which  so  commonly  exist  between 
the  prepuce  and  the  glans  are  as  a  rule  easily 
separated,  but  occasionally  they  are  so  firm  as  to 
require  sharp  dissection.  In  such  a  case  the  author, 
after  dissecting  the  prepuce  from  the  glans,  folded 
the  redundant  prepuce  on  itself  so  that  a  short  pre- 
puce was  formed  lined  with  epidermis  and  so 
reformation  of  adhesions  was  prevented.  Possibly 
it  would  have  been  well  to  have  covered  the  raw 
surface  of  the  glans  with  skin  grafts. 

Paraphimosis. — The  foreskin  is  retracted,  swol- 
len, and  cannot  be  brought  forward.    The  constricting 
band  obstructing  reduction  is  the  margin  of  the  preputial  orifice  (the  muco- 
cutaneous junction).     The  retracted  foreskin  forms  two  swellings  surrounding 
the  penis;  the  constricting  band  lies  in  the  groove  between  the  swellings. 

A.  By  manipulations  endeavor  to  push  back  the  glans  and  bring  forward 
the  prepuce.  If  successful,  advise  or  perform  circumcision  to  prevent  recur- 
rence. 

B.  If  manipulation  fails,  operate.  With  the  fingers  separate  the  anterior 
from  the  posterior  penile  swellings  and  so  expose  the  constricting  band.  Di\dde 
the  band  in  the  mid-dorsal  line;  reduction  is  now  easy.  (Fig.  722.)  Advise 
or  practise  circumcision. 


Fig.   722. — {Veau.) 


CHAPTER  LIII. 
OPERATIONS  ON  THE  TESTICLES. 

CASTRATION;  ORCHIDECTOMY;  ORCHI-EPIDIDYMECTOMY. 

I.  Simple  Castration. — Step  i. — Make  an  incision  2  or  2  1/2  inches 
in  length  downwards  from  the  level  of  the  external  abdominal  ring.  Through 
this  isolate  the  spermatic  cord  by  blunt  dissection. 

Step  2. — If  the  cord  is  not  very  thick,  crush  it  forcibly  with  powerful  for- 
ceps. In  the  groove  formed  by  the  clamp  tie  a  ligature  tightly  around  the 
whole  cord.  Thread  one  end  of  the  ligature  on  a  needle  and  pass  it  through 
a  small  portion  of  the  cord  distal  to  the  main  ligature.  Once  more  tie.  This 
stitch  obviates  any  possibility  of  the  ligature  slipping.  Some  surgeons  care- 
fully avoid  including  the  vas  deferens  in  the  ligature  lest  pain  result.  Jacob- 
son  believes  that  if  the  ligature  be  applied  very  tightly  pain  will  not  develop. 
Crushing  the  cord  before  applying  the  ligature  has  the  same  effect.  When 
the  cord  is  large,  or  if  for  any  reason  a  single  ligature  seems  objectionable, 
two  or  more  interlocked  ligatures  may  be  applied.  Absorbable  or  non-ab- 
sorbable  ligatures  may  be  used  at  the  option  of  the  surgeon.  Plain  or  iodized 
catgut  serves  every  purpose  excellently.  Apply  a  clamp  to  the  cord,  about 
one  inch  distal  to  the  ligature.  Divide  the  cord  between  the  clamp  and  ligature. 
Examine  the  ligated  stump,  which  may  be  allowed  to  retract  into  the  inguinal 
canal  if  it  is  healthy  and  is  not  bleeding. 

Step  3. — With  the  hand  on  the  scrotum  make  the  testicle  with  its  coverings 
protrude  through  the  wound.  By  blunt  dissection,  separate  it  with  its  cover- 
ings from  the  scrotum,   and   so   remove  it. 

Step  4. — Carefully  review  the  wound  and  stop  all  bleeding.  If  drainage 
is  required,  perforate  the  scrotum  at  a  dependent  point,  and  through  the 
perforation  introduce  a  capillary  or  tubular  drain. 

Step  5. — Close  the  wound  with  sutures.  The  objects  in  making  the  skin- 
incision  at  a  high  rather  than  a  low  level  are:  (a)  It  is  more  easy  to  separate 
the  cord  and  the  testicle  from  their  surroundings;  (6)  the  whole  vascular  sup- 
ply is  under  control  from  the  beginning;  (c)  it  is  much  easier  to  retain  suitable 
dressings  over  the  wound. 

II.  Castration  for  Malignant  Disease. — This  operation  as  commonly 
performed  is  a  farce  and  recurrence  is  certain.  The  usually  described  method 
is  that  of  simple  castration,  which  is  as  ineffective  as  simple  excision  of  the 
cancerous  breast  when  the  axillary  glands  are  involved.  WTien  the  testicle 
is  the  seat  of  malignant  disease,  the  same  principle  holds  good  as  in  the  case 

615 


6l6  OPERATIONS    ON   THE    TESTICLES. 

of  the  breast,  viz.,  to  remove  en  masse  the  whole  organ  plus  all  the  accessible 
lymphatic  tissue  through  which  it  is  normally  drained.  Unfortunately, 
the  terminal  lymphatics  are  not  accessible.  The  lymphatics  of  the  testicle, 
epididymis,  and  visceral  layer  of  the  tunica  vaginalis  fun  along  the  spermatic 
cord  to  the  lumbar  region.  They  are  usually  superficial  to  but  in  contact 
with  the  blood-vessels.  In  the  lumbar  region  they  leave  the  spermatic  vessels 
and  run  towards  their  terminal  glands.  The  terminal  glands  are  grouped 
around  the  aorta  (right  and  left  juxta-aortic  glands)  (Cuneo).  The  lymphatics 
of   the   scrotum    terminate   in    the   inguinal   glands. 

Cumston  and  Rolfe  ("American  Med.,"  1903,  607)  have  given  a  good 
description  of  the  methods  to  be  employed;  the  following  is  largely  based 
on   their  paper. 

Step  I. — Make  an  incision  parallel  to  and  one  inch  above  Poupart's  liga- 
ment from  a  point  a  little  below  the  external  inguinal  ring  to  a  point  about 
one  inch  above  the  internal  ring, 

Slep  2. — Expose  the  fascia  of  the  external  oblique  and  split  it,  as  in  Bassini's 
hernial  operation,  from  the  external  ring  to  a  little  above  the  internal  ring. 
Retract  the  flaps  of  fascia  thus  formed. 

Slep  3. — Push  the  internal  oblique  muscle  aside  and  thus  expose  the  in- 
guinal canal  and  spermatic  cord.  Dissect  the  cord  from  its  bed.  Open 
the  posterior  wall  of  the  inguinal  canal  and  invade  the  iliac  fossa. 

Slep  4. — The  elements  composing  the  cord  become  separated  at  the  internal 
ring,  the  vas  going  down  towards  the  small  pelvis,  the  spermatic  vessels  and 
lymphatics  going  up  towards  the  lumbar  region,  on  the  psoas  muscle.  Follow 
the  vas  deferens  as  far  as  possible  towards  the  deep  pelvis  and  there  ligate 
and  divide  it.  Cauterize  its  stump  with  pure  carbolic  acid  or  the  cautery. 
Follow  the  spermatic  vessels  up  towards  the  lumbar  region  as  far  as  possible 
and   there   doubly  ligate   and   divide   them. 

Step  5. — Beginning  above  at  the  site  of  division  of  the  vas  and  of  the  sper- 
matic vessels,  separate  the  cord  and  its  envelopes  downwards,  to  a  point  below 
the  external  inguinal  ring.  By  pressing  on  the  scrotum  it  is  easy  to  deliver 
the  testicle  with  its  envelopes  through  the  wound  and  remove  them  together 
with  the  cord.  If  the  scrotum  is  adherent  to  the  testicle,  make  a  liberal  ex- 
cision of  the  scrotal  skin  and  all  the  structures  between  it  and  the  testicle. 
This  is  done  by  continuing  the  original  incision  downwards  and  making  it 
surround  the  affected  area.  Remember  that  if  the  scrotum  is  involved  the 
inguinal  lymphatic  glands  may  be  affected  and  should  be  removed,  as  it  is 
into  them  that  the  scrotal  lymphatics  drain. 

Step  6. — Review  the  wound  with  care  and  attend  to  hemostasis.  Close 
the  wound  exactly  as  in  an  operation  for  the  radical  cure  of  hernia. 

Epididymectomy. — This  operation  may  be  done  alone  or  vasectomy  may 
be  added  to  it. 

Step  I, — Make  an  incision  into  the  tunica  vaginalis,  just  external  and 
parallel  to  the  epididymis.     If  the  epididymis  is  adherent  to  the  skin  or  fistula 


EPIDIDYMECTOMY. 


617 


are  present,  such  adherent  skin  and  fistulae  should  be  surrounded  by  elliptical 
incisions  and   removed   with   the   epididymis. 

Step  2. — Make  an  incision  along  the  junction  between  the  epididymis 
and  testicle  on  the  outer  side.  This  incision  divides  the  serous  membrane 
alone  opposite  the  body  of  the  epididymis,  while  at  the  head  and  tail  (globus 
major  and  minor)  it  divides  the  tunica  albuginea.  With  knife  or  scissors 
separate  the  head  (globus  major)  from  the  testicle.  Next  separate  the  body 
of  the  epididymis  from  the  testicle  (Fig.  723).  As  the  inner  side  of  the  junction 
between  the  epididymis  and  testicle  is  reached,  proceed  with  great  care,  be- 
cause here  the  vessels  going  to  the  testicle  are 
in  contact  with  the  epididymis.  By  making 
slight  traction  and  putting  the  structures  of 
the  cord  gently  on  the  stretch,  it  becomes  easy 
to  separate  the  epididymis  from  the  vessels. 

Step  3. — The  epididymis  being  free,  con- 
tinue the  dissection  by  separating  the  vas 
from  its  surroundings  up  to  the  internal  ring, 
"where  it  is  grasped  on  both  sides  of  its  cir- 
cumference with  hemostatic  forceps,  divided, 
and  the  lumen  of  the  proximal  end  cauterized 
with  95  per  cent,  carbolic  acid  on  the  end  of 
a  needle.  The  needle  is  to  be  worked  up- 
wards in  the  lumen  for  1/2  inch  and  the 
mucous  memberane  thoroughly  cauterized." 
Ligate  the  proximal  end  of  the  vas.  This  is 
important  in  that  it  prevents  infectious  ma- 
terial being  voided  from  the  vas  into  the  tissues. 

Step  4. — Review  the  wound  made  in  the  testicle  by  the  removal  of  the 
epididymis.  If  any  foci  of  disease  are  found,  excise  them  by  wedge-shaped 
incisions  and  close  the  wounds  with  fine  catgut.  Suture  with  catgut  any  wound 
in  the  tunica  albuginea.  If  the  condition  of  testicle  makes  one  suspect  disease 
in  it,  it  is  proper  to  make  an  exploratory  incision  into  it.  Such  incision  must 
be  closed  with  catgut  sutures  should  no  further  procedure  be  indicated. 

Step  5. — Having  attended  to  hemostasis,  close  the  external  wound  with 
sutures.  It  is  well  to  provide  drainage  for  twenty-four  or  forty-eight  hours. 
In  some  cases  it  is  possible  to  remove  disease  from  the  epididymis  by  partial 
or  complete  excision  of  that  organ,  without  removing  so  much  of  the  vas 
as  was  recommended  in  the  preceding  paragraphs.  When  this  is  possible, 
one  may  follow  the  suggestion  of  Bardenheuer,  which  was  first  carried  out 
by  Rasumowsky  ("Archiv  f.  klin.  Chir.,"  Ixv,  p.  557),  viz.,  to  make  an  anasto- 
mosis between  the  vas  and  the  rete  testis  or  the  remnants  of  the  epididymis. 

Anastomosis  between  the  Vas  Deferens  and  the  Rete  Testis. — Step 
I. — Completely  excise  the  epididymis,  removing  as  little  of  the  vas  deferens 
as  possible. 


Fig.   7 


{Monod  and  Vanverts.) 


6i8 


OPERATIONS    ON    THE    TESTICLES. 


Step  2. — rPass  a  fine  probe  or  director  into  the  vas  and  with  this  as  a  guide 
split  the  vas  for  a  little  less  than  half  an  inch. 

Step  3. — With  fine  catgut  sutures,  introduced  in  the  Lembert  fashion, 
unite  the  gaping  end  of  the  vas  to  that  part  of  the  testicle  from  which  the  head 
of  the  epididymis  was  removed  (rete  testis,  beginning  of  the  coni  vasculosi). 

Step  4. — Partially  bury  in  the  testicle  the  site  of  anastomosis,  by  means 
of  a  few  heavy  sutures  introduced  in  the  Lembert  fashion  (Fig.   724). 

Step  5. — Cover  the  line  of  sutures  in  the  testicle  by  closing  with  catgut 
the    wound   in    the    tunica   vaginalis,    etc.     Close    the    skin-wound. 

Anastomosis  between  the  Vas  Deferens  and  the  Epididymis  after 
Partial  Excision  of  the  Latter. — Step  i. — Excise  the  tail  and  part  of  the 
body   of   the   epididymis,    dividing   the   body   transversely. 


Fig.  725. 


Step  2. — Split  the  vas  for  about  1/2  inch,  and  introduce  into  it  (in  the 
Lembert  fashion)  two  fine  catgut  sutures. 

Step  3. — Perforate  or  tunnel  the  remaining  portion  of  the  epididymis  (head 
and  part  of  body)  with  a  pointed  knife  introduced  through  its  cut  surface. 
Through  this  tunnel  pass  by  means  of  needles  the  catgut  sutures  attached 
to  the  vas  (Fig.  725). 

Step  4. — By  pulling  on  the  catgut  threads  insinuate  the  open  end  of  the 
vas  into  the  tunnel  and  fix  it  there  by  tying  the  catgut  sutures.  One  or  two 
extra   sutures   may   be   used   to   complete   the   union. 

Step  5. — Close  the  wound  in  the  overlying  tissues  by  one  or  more  layers 
of  catgut  sutures. 

Excision  of  the  Vas  Deferens  with  or  without  the  Seminal  Vesicle; 
Vasectomy. — The  term  "vasectomy"  is  properly  applied  to  this  operation, 
but  custom  seems  to  have  limited  its  use  to  the  mere  division  or  removal  of 
a  small  segment  of  the  vas  in  cases  of  prostatic  hypertrophy.  Vasectomy, 
in  the  latter  limited  sense,  is  performed  by  incising  the  skin  immediately 
below  the  external  abdominal  ring,  exposing  the  cord,  separating  the  vas  from 
the  other  structures  of  the  cord,  and  dividing  it  between  two  ligatures.     J.  W. 


VASECTOMY.  619 

White  and  R.  Harrison  have  found  much  benefit  result  from  this  simple 
operation.  Vasectomy,  in  the  wider  and  proper  sense  of  the  term,  is  a  much 
more  serious  procedure — so  difficult,  indeed,  that  a  number  of  operators  have 
discarded   its   use.     Vasectomy   may   be  partial   or   complete. 

Partial  Vasectomy. — The  scrotum  has  been  opened  and  the  testicle  or 
the  epididymis  has  been  excised.  The  divided  end  of  the  vas  (if  not  still 
attached  to  the  testis  or  epididymis)  is  seized  in  forceps  to  prevent  its  retraction. 
Continue  the  skin-incision  upwards  and  outwards.  Open  the  inguinal  canal 
by  incising  the  aponeurosis  of  the  external  oblique.  Separate  the  vas  from 
the  cord  up  to  or  within  the  internal  abdominal  ring.  Doubly  ligate  the 
vas  at  as  high  a  point  as  possible  and  divide  it,  being  careful  to  cauterize  the 
stump.  Attend  to  hemostasis  and  close  the  wound.  In  many  cases 
this  partial   operation   suffices. 

Von  Biingner,  instead  of  excising  the  vas  as  above,  merely  follows  it  to 
the  external  abdominal  ring  and  endeavors  to  remove  the  rest  of  it  by  avulsion, 
in  the  same  manner  as  Thiersch  extracts  nerves.  This  method  might  be 
practicable  if  the  vas  to  be  removed  was  sound,  but  it  is  diseased  and  gives 
way  at  its  weakest  point,  which  is  a  diseased  point.  Theoretically,  the  method 
is    bad. 

Complete  Vasectomy  with  or  without  Excision  of  the  Seminal  Vesicle. — 
Baudet  and  Duval  have  systematized  this  operation  very  thoroughly.  Place 
the  patient  in   Trendelenburg's   position.     Excise   the   testis   or   epididymis. 

Step  I. — Continue  the  scrotal  wound  up  to  the  external  abdominal  ring 
and  along  the  inguinal  canal  to  a  point  two  fingerbreadths  internal  to  the  an- 
terior  superior  iliac   spine. 

Step  2. — Open  the  inguinal  canal  by  incising  the  aponeurosis  of  the  ex- 
ternal oblique.  Divide  the  internal  oblique  and  transversalis  along  the  line 
of  the  skin-incision.  Divide  the  transversalis  fascia  without  injuring  the 
peritoneum. 

Step  3. — With  the  finger  strip  the  peritoneum  off  the  iliac  fossa.  Do 
not  strip  off  any  of  the  fascia  with  the  peritoneum.  It  is  important  to  keep 
between  these  two  structures. 

Step  4. — Incise  the  sheath  of  the  spermatic  cord  and  look  for  the  vas  beside 
the  pubic  spine.  With  blunt  dissection  follow  and  isolate  the  vas  first  towards 
the  iliac  fossa  and  then  on  the  peritoneum,  which  is  retracted  inwards  by  a 
wide  retractor.  Do  not  exert  any  traction  on  the  vas.  Use  the  eye  rather 
than  the  finger  as  a  guide.  During  this  dissection  retract  the  epigastric  artery 
forwards,  the  umbilical  downwards  and  outwards.  As  the  wound  becomes 
deeper  carry  out  the  dissection  with  forceps.  When  a  point  deep  down  in  the 
pelvis  is  reached,  note  a  "tent-like"  ridge  passing  transversely  inwards  from  the 
pelvic  wall.  This  is  composed  of  the  vesicular  vessels  covered  by  aponeurosis, 
and  here  the  vas  deferens  enters  the  vesicular  space.  If  the  operation  is 
to  consist  of  complete  vasectomy  alone,  doubly  ligate  the  vas,  divide  and 
remove  it.     If  it  is  desired  to  remove  the  seminal  vesicle,  proceed  to  Step  5. 


620  OPERATIONS    ON    THE    TESTICLES. 

Step  5. — Make  a  transverse  tear  in  the  fascia  covering  the  vesicular  vessels. 
Retract  the  edges  of  the  fascial  vi^ound.  Doubly  ligate  and  divide  the  vessels. 
Beneath  the  vessels  lies  the  pale,   rather  sinuous  seminal  vesicle. 

Step  6. — Seize  the  base  of  the  vesicle  with  a  clamp  and  isolate  it  from  its 
sheath,  being  careful,  during  the  dissection,  to  keep  in  close  contact  with 
the  vesicle  so  as  to  avoid  hemorrhage.  The  deep  portion  of  the  vas  is  easily 
separated  from  the  peritoneum  and  bladder;  it  lies  along  the  inner  side  of 
and  is  closely  attached  to  the  vesicle. 

Step  7. — With  scissors  separate  the  vas  and  seminal  vesicle  from  the  pros- 
tate.    Cauterize   the   stump. 

Step  8. — The  most  of  the  huge  wound  promptly  closes  itself  as  soon  as 
the  retractors  are  removed.  It  is  well  to  place  a  cigarette  drain  into  the  depth 
of  the  wound.  Close  the  wound  in  the  parietes  in  the  same  fashion  as  in 
the  radical  cure  of  hernia. 

Young's  Operation. — ("Annals  of  Surgery,"  Oct.,  1900,  and  Nov.,  1901.) 
"Suprapubic  retrocystic  extraperitoneal  resection  of  the  seminal  vesicles 
and  vasa  deferentia."  In  several  cases  Young  has  successfully  performed 
this  most  difficult  operation,  and  has  at  the  same  time  excised  portions  of 
the  urinary  bladder. 

Make  a  vertical  median  incision  from  the  pubis  to  a  point  above  the  um- 
bilicus. At  the  upper  end  of  this  make  a  transverse  incision  dividing  both 
recti  muscles.  These  incisions  penetrate  to  but  do  not  involve  the  peritoneum. 
Retract  the  edges  of  the  wound.  Beginning  below,  dissect  the  peritoneum 
from  the  anterior  bladder-wall  up  to  and  including  the  vertex  of  the  bladder. 
At  the  vertex  the  separation  is  difficult.  Continue  the  separation  down  the 
posterior  bladder-wall  until  the  seminal  vesicles  and  vasa  deferentia  are  ex- 
posed. Remove  these,  and  with  them  any  diseased  portions  of  the  prostate 
and  bladder.  (Young  has  removed  about  one-half  of  the  bladder.)  Close 
the  bladder  wound  by  sutures.  Provide  for  drainage.  Close  the  abdominal 
wound. 

Several  methods  have  been  devised  for  the  exposure  and  removal  of  the 
seminal  vesicles  through  the  perineum.  These  are  so  similar  to  some  of 
the  methods  described  for  the  exposure  of  the  prostate  that  they  need  not  be 
dilated  upon.  Schede  has  used  the  sacral  and  parasacral  routes  to  reach 
the  seminal  vesicles,  but  other  routes  seem  as  efficient  and  much  less  formidable. 

Remarks  on  Castration,  Epididymectomy,  Vasectomy,  and  Vesicu- 
lectomy.— In  cases  of  malignant  disease  of  the  testicle  or  epididymis  it  is 
necessary  to  abide  by  the  rule,  do  too  much  rather  than  too  little.  The  freest 
possible  excision  of  all  tissue  which  may  possibly  be  infected  is  compulsory, 
whether  that  tissue  shows  any  signs  of  disease  or  not.  Only  by  conscientiously 
working  along  the  lines  of  thoroughness  can  improved  results  be  obtained. 
When  the  disease  necessitating  operation  is  tuberculosis,  no  such  "hard- 
and-fast"  rules  meet  with  universal  approval.  Konig  more  than  any  other 
surgeon  has  advanced  our  knowledge  of  the  surgery  of  tuberculosis,   and 


REMARKS.  621 

hence  his  opinion  ought  to  carry  great  weight.  This  surgeon,  and  with  him 
Kocher,  Terrilon,  Senn,  etc.,  declares  in  favor  of  castration  (orchidectomy) 
in  cases  of  tuberculosis  suitable  for  operation.  When  epididymectomy  is 
performed,  it  is  feared  that  tuberculous  foci  may  be  left  in  the  testicle  and 
cause  further  trouble,  and  it  is  assumed  that  no  usefiil  fvuiction  can  be  per- 
formed by  the  imperfect  organ  left  behind.  J.  B.  Murphy,  Tillaux,  and 
others  draw  attention  to  the  fact  that  the  testicle  has  a  useful  influence  on  the 
general  metabolism  which  must  not  be  disregarded.  The  glandular  portion 
of  the  testicle  is  practically  never  primarily  and  rarely  secondarily  affected  to 
a  serious  extent.  The  results  of  Bardenheuer  and  Murphy  show  that  epi- 
didymectomy is  as  curative  as  is  castration.  In  suitable  cases  it  may  be  well 
to  attempt  anastomosing  the  vas  to  the  testicle.  Bogoljuboff's  experiments 
("Archiv  f.  klin.  Chir.,"  Ixxii  p.  449)  show  that  this  operation  does  actually 
provide  direct  communication  between  the  tubules  of  the  testicles  and  the 
vas.     The  status  of  the  operation  is,  however,  by  no  means  fixed  as  yet. 

J.  B.  Murphy  considers  epididymectomy  contraindicated  (i)  where  there 
are  extensive  tubercular  lesions  elsewhere  which  will  shortly  terminate  the 
patient's  life.  (2)  Where  the  disease  has  extended  to  and  destroyed  the  greater 
part  or  all  of  the  testis  proper.  Here  castration  should  be  done.  (3)  Where 
the  scrotum  is  riddled  with  discharging  sinuses.  The  indication  is  usually 
here  also  for  castration.  Apart  from  these  three  conditions,  in  every  case  a  re- 
section, typical  or  atypical,  should  be  done.  Murphy  also  points  out  that  after 
epididymectomy  (without  anastomosis)  "sexual  desire  and  potency,  even  to 
emissions,  are  retained;  power  of  procreation,  however,  is  lost." 

Horwitz  comes  to  conclusions  which  are  very  similar  to  and  support  those  of 
Murphy. 

In  a  large  number  of  cases  in  which  there  has  been  evidence  of  involvement 
of  the  vas,  seminal  vesicle,  and  even  bladder,  simple  epididymectomy,  with  or 
without  any  extensive  vasectomy,  has  given  excellent  results.  In  these  cases 
it  appears  as  if  nature  was  able  successfully  to  combat  the  secondary  lesions 
when  the  primary  one  was  eliminated.  The  profound  influence  exerted  on  the 
prostate,  etc.,  by  castration  or  epididymectomy  probably  effectually  aids  nature 
in  her  combat. 

When  the  gravity  of  operations  for  complete  vasectomy  and  vesiculec- 
tomy is  considered,  and  the  frequency  with  which  all  evidences  of  disease  dis- 
appear from  the  neck  of  the  bladder  after  simple  epididymectomy  and  partial 
vasectomy,  it  appears  wise  to  be  conservative.  Young's  advice  is  excellent, 
viz.,  to  abstain  from  operations  on  the  seminal  vesicles  and  prostate  until  such 
time  as  it  is  demonstrated  that  removal  of  the  testicular  foci  has  failed  to  arrest 
the  progress  of  the  disease  in  these  organs  and  it  has  spread  to  the  bladder. 
According  to  Young  serious  involvement  of  distant  parts,  pulmonary,  urinary, 
osseous,  etc.,  does  not  contraindicate  operation.  Removal  of  the  local  lesions 
often  has  a  very  satisfactory  effect  on  the  distant  foci. 

Operative    Treatment    of    Undescended    and   Misplaced    Testicle. — 


622 


OPERATIONS    ON    THE    TESTICLES. 


There  are  several  types  of  undescended  and  misplaced  testicle.  The  testis  may 
be  situated  (a)  in  the  abdomen  near  its  original  position;  (b)  at  the  internal  ring; 
(c)  in  the  inguinal  canal;  (d)  outside  the  external  ring;  (e)  in  the  perineum; 
(/)  on  the  thigh  below  Poupart's  ligament. 

No  matter  where  the  testis  is  located,  the  principles  of  treatment  are  identi- 
cal. These  principles  are:  (i)  Proper  exposure  of  the  organ.  (2)  Thorough 
relief  of  tension  so  that  the  organ  may  be  brought  into  the  desired  place  (the 
scrotum)  and  may  tend  to  stay  there  of  itself.  (3)  Proper  preparation  of  the 
bed  in  which  the  testis  is  to  lie.  (4)  Selection  of  proper  time  for  operation. 
Undoubtedly  the  changes  incident  to  puberty  will  take  place  more  completely 
in  the  testicle  when  it  lies  in  its  natural  position  in  the  scrotum;  hence  the  age 
of  selection  for  operation  is  before  puberty,  when  the  patient  is  from  six  to  twelve 
years  old. 

A.  D.  Bevan  ("Jour.  Am.  Med.  Assoc,"  Sept.  19,  1903)  has  thrown  much 
light  on  the  condition  under  discussion,  and  the  following  paragraphs  are  based 
on  his  writings: 


yoginal proceii  hgoted 


yyd Spermohc  vesstfi  ■ 


Purie  itrinq 


--''a  tunica  Vagina hs. 


\iSpermafic  reae/s 
/ifafet/  S  <f/yi(^K/ 
tliii  li  i4Uom  necfuary 


Fig.  726.  Fig.  727. 

Figs.  726  and  727. — (Bevan.) 


(A)  The  testicle  is  in  the  inguinal  canal  or  outside  the  external  ring. 

Step  I. — Make  an  incision  from  the  external  ring  upwards  and  outwards 
for  a  distance  of  three  inches.  This  incision  is  like  that  made  in  Bassini's 
operation  for  inguinal  hernia  and  does  not  involve  the  scrotum.  Divide  and 
retract  the  aponeurosis  of  the  external  obUque  as  in  the  hernia  operation.  Divide 
the  cremasteric  and  thin  transversalis  fasciae  throughout  the  length  of  the 
wound. 

Step  2. — Note  the  peritoneal  pouch  containing  the  testicle.  Open  this 
pouch  and  expose  the  testicle.  Divide  the  peritoneum  above  the  testicle  and 
carefully  separate  it  from  the  cord,  as  in  a  hernia  operation.  Close  the  stump 
of  peritoneum  by  suture  or  ligature.  With  a  purse-string  suture  close  the  por- 
tion of  peritoneal  sac  in  contact  with  the  testicle  and  so  form  a  tunica  vaginalis 
(Fig.  726). 


BEVAN  S    OPERATION. 


623 


Step  3. — Lift  the  testicle  out  of  its  bed.  Pull  gently  on  the  cord  to  lengthen 
it  as  much  as  possible.  Shortened  bands  of  connective  tissue  will  be  seen  as 
tense  bands  in  the  cord.  Tear  through  these  bands  with  forceps.  Strip  the 
cord  of  all  the  surrounding  fascia,  leaving  nothing  but  the  vessels  and  the  vas. 
Separate  the  spermatic  vessels  and  vas,  which  lie  behind  the  posterior  layer  of 
peritoneum  of  the  abdominal  cavity,  from  the  peritoneum  by  blunt  dissection. 
"The  spermatic  vessels  will  be  found  passing  upwards  and  inwards,  and  the 
vas  downwards  and  inwards  from  the  internal  ring."  The- above  manoeuvres 
should  so  lengthen  the  cord  that  the  testicle  may  be  laid  on  the  thigh  three  or 
four  inches  below  Poupart's  ligament  (Fig  728).  Unless  lengthening  of  the 
cord  is  obtained  to  the  extent  mentioned,  other  measures  must  be  adopted  to 
secure  the  requisite  relief  of  tension. 


esticlefreed  ^^^  / 
and  ready /or^^~ 
replacement 


Fig.   728.— (Sei'aw.) 


Step  4. — ^Pass  the  fingers  from  the  wound  into  the  scrotum  and  form  a  pocket 
there.  Into  this  pocket  tuck  the  testicle.  Close  the  mouth  of  the  pocket  by 
a  purse-string  suture  passing  through  both  the  external  and  internal  pillars  of 
the  external  abdominal  ring,  above  the  cord.  Do  not  let  the  suture  exercise 
pressure  on  the  cord. 

Ombredanne  ("La  Presse  Med.,"  Oct.  8,  1910)  passes  a  finger  from  the 
wound  into  the  bottom  of  the  scrotum  on  the  same  side  and  then  pushes  the 
finger  transversely  through  the  septum  into  the  other  side  of  the  scrotum  where 
he  incises  the  skin  (Fig.  729).  A  forceps  passed  the  scrotal  skin  wound  follows 
the  finger  as  it  is  withdrawn  to  emerge  at  the  inguinal  wound  where  it  grasps 
a  suture  inserted  into  the  tunica  vaginalis  formed  in  Step  2.  By  pulling  on 
the  suture  the  testicle  is  pulled  through  the  septum  to  the  opposite  side  of 
the  scrotum,  where  it  is  easily  fixed  by  a  few  stitches. 

Step  5. — Close  the  wound  as  in  a  Bassini  operation,  but  instead  of  dislocating 
the  cord,  sew  the  conjoined  tendon  and  Poupart's  ligament  together  above, 
i.  e.,  superficial  to  the  cord. 


624 


OPERATIONS    ON    THE    TESTICLES. 


(B)  Where  it  is  impossible  to  get  the  requisite  lengthening  of  the  cord  by  the 
means  described  in  Step  3,  or  when  the  testicle  is  intraabdominal,  the  following 
measures  suffice:  Open  the  inguinal  canal.  Expose  the  testis;  if  necessary, 
"hook"  it  out  of  the  abdominal  cavity  with  the  finger.  The  obstacle  to  the 
descent  of  the  testicle  is  not  the  vas,  but  the  spermatic  vessels.     Division  of 


Fig.  729. — {Omhredanne .) 

these  does  no  harm  to  the  testis.  This  was  pointed  out  many  years  ago  by 
Bennet,  and  agrees  with  the  writer's  experience.  The  testicle  gets  a  sufficiency 
of  nourishment  through  the  artery  of  the  vas.  Doubly  ligate  and  divide  the 
spermatic  vessels  (Fig.  727).  When  this  is  done,  it  is  easy  to  bring  the  testicle 
down  into  the  scrotum. 


CHAPTER  LIV. 
HYDROCELE. 

Tapping  a  Hydrocele. — Clean  the  scrotum.  Ascertain  the  position  of  the 
testicle  by  palpation;  the  patient's  sensations  aid,  so  does  the  translucency 
test.  Place  the  left  hand  behind  the  scrotum  and  grasp  it  so  as  to  render  its 
anterior  surface  tense.  Choose  a  point  on  the  lower  anterior  surface  free  from 
veins  and  at  this  place  thrust  a  trocar  and  cannula  upwards  and  backwards  to 
a  depth  of  about  one  inch.  Avoid  thrusting  towards  the  testicle.  Withdraw 
the  trocar  and  let  the  fluid  escape  through  the  cannula,  keeping  up  pressure 
with  the  left  hand.  AAHien  the  fluid  is  all  evacuated  withdraw  the  cannula. 
Dress  the  puncture  with  collodion  or  leave  it  to  the  care  of  nature  which  is  usually 
equally  good. 

Radical  Cure  of  Hydrocele. — I.  Injection  Method. — A.  Iodine  Injection. — 
Tap  the  hydrocele  completely.  Inject  through  the  cannula  about  half  an  ounce 
of  tincture  of  iodine.  Withdraw  the  cannula.  Rub  the  scrotum  gently  be- 
tween the  hands  to  insure  even  distribution  of  the  iodine  throughout  the  sac. 
Within  twenty-four  to  thirty-six  hours  there  is  much  swelling  and  pain  in  the 
scrotum  but  this  soon  subsides.  After  two  or  three  weeks  recovery  ensues 
though  a  suspensory  bandage  is  often  required  for  some  time. 

B.  Carbolic  Acid  Injection. — Tap  and  inject  about  ten  drops  of  liquefied 
carbolic  acid  in  the  same  manner  as  with  iodine.  It  is  difficult  to  inject 
through  the  cannula  such  a  small  quantity  of  liquid,  hence  the  following  method 
is  better.  By  tapping  withdraw  most  but  not  all  of  the  liquid.  Charge  a 
hypodermic  syringe  with  the  carbolic  acid.  Puncture  the  hydrocele  with  the 
hypodermic  needle  until  the  needle  touches  the  cannula,  thus  making  sure  that 
its  point  is  really  inside  the  sac.  Permit  the  rest  of  the  hydrocele  fluid  to  escape 
through  the  cannula.  Withdraw  the  cannula.  Discharge  the  hypodermic 
syringe  and  withdraw  it.  The  results  of  injecting  carbolic  acid  are  as  good  and 
less  painful  than  when  iodine  is  used. 

II.  Incision. — Volkmann's  operation.  Make  an  incision,  not  less  than  i  | 
inches  long,  into  the  sac.  Suture  the  wound  in  the  sac  to  the  skin.  Drain 
with  tube  or  gauze.     Apply  dressings. 

III.  Excision. — Bergmann's  operation.  Through  the  skin  make  an  incision 
extending  from  near  the  upper  to  near  the  lower  end  of  the  hydrocele.  Expose 
the  sac  and  by  blunt  and  sharp  dissection  separate  it  from  its  coverings  until 
its  connections  with  the  testicle  are  reached.  Open  the  sac  and  trim  it  oflf 
close  to  the  testicle.  Attend  to  haemostasis.  Close  the  wound  with  or  without 
drainage.     In  scrotal  wounds  the  writer  usually  inserts  a  very  Jew  interrupted 

40  625 


626  HYDROCELE. 

sutures  between  which  it  is  easy  for  fluids  to  escape.     Apply  dressings  and 
support  the  scrotum. 

IV.  Eversion  of  Hydrocele  Sac. — Jaboulay's  operation.  Make  an  incision 
into  the  hydrocele.  Bring  the  testicle  out  through  the  wound.  Ligate  and 
divide  the  gubernaculum  testis.  Fold  the  two  sides  of  the  divided  sac  behind 
the  testicle  and  fix  them  there  by  a  few  sutures,  one  of  which  must  interest  the 
superficial  tissues  of  the  cord.  Reduce  the  testicle.  Close  the  scrotal  wound, 
by  a  few  sutures  (Fig.  730).  This  is  a  very  satisfactory,  easy  and  rapid  operation. 


P'iG.  730. — (Duval.) 

Hydrocele  of  the  Cord. — A.  Small  hydroceles  or  cysts  of  the  cord.  Expose 
the  sac  by  an  incision  almost  as  long  as  itself.  Pick  up  the  upper  end  of  the  sac 
in  the  fingers  and  remove  it  if  possible  unbroken  by  gauze  dissection.*  Close 
the  wound. 

B.  Hydrocele  of  larger  size  than  the  preceding. 

(a)  Incise  and  drain. 

(6)  Excise  most  of  the  sac  wall. 

(c)  Eversion  method.  Incise.  Turn  the  walls  of  the  sac  back  and  fix  with 
sutures  on  the  other  side  of  the  cord. 

*  Gauze  dissection.  Blunt  dissection  may  be  carried  out  with  instruments  or  with  the 
fingers.  If  a  "sponge"  or  "wipe"  of  gauze  is  used  over  the  tips  of  the  finger  the  dissection 
is  more  satisfactory.     This  constitutes  gauze  dissection. 


CHAPTER  LV. 
VARICOCELE. 

Open  Operation. — Step  i. — Make  an  incision  paralled  to  and  directly  over 
the  cord.  The  incision  should  be  i  to  1 1/2  inches  long  and  its  upper  end  cor- 
respond to  the  external  abdominal  ring.  Layer  by  layer  di\-ide  the  tissues 
until  the  cord  is  exposed. 

Step  2. — Pick  up  the  whole  cord  and  isolate  it  from  the  external  abdominal 
ring  to  the  testicle.  This  is  easy.  Recognize  the  vas  which  feels  like  whip- 
cord. Separate  the  vas  and  with  it  a  very  few  veins,  from  the  rest  of  the  struc- 
tures forming  the  cord  and  hold  it  aside. 

Step  3. — ^Apply  a  crushing  forceps  near  the  external  abdominal  ring  to  the 
mass  of  veins  to  be  removed.  Similarly  apply  a  crushing  forceps  or  clamp  to 
the  same  mass  of  veins  near  the  testicle.  Remove  the  crushing  clamps.  Tie 
catgut  ligatures  round  the  veins  in  the  grooves  left  by  the  clamps.  Cut  away  the 
veins  between  the  ligatures  leaving  sufficient  stump  to  prevent  slipping  of  the 
ligatures.  The  only  objects  in  using  the  crushing  clamps  are  to  provide  a  groove 
in  which  the  ligatures  can  lie  and  to  permit  the  use  of  a  finer  thread  than  would 
otherwise  be  necessary. 

Step  4. — Bring  the  two  venous  stumps  together  and  keep  them  together  by 
a  stitch  or  by  tying  the  upper  to  the  lower  ligature. 

Step  5. — Close  the  wound  with  or  without  drainage. 

Remarks. — The  incision  is  made  at  the  level  of  the  external  abdominal  ring 
because  at  this  place  (a)  it  is  very  easy  to  isolate  the  cord,  (b)  it  is  very  easy  to 
apply  dressings  after  the  operation. 

On  recovery,  a  suspensory  bandage  ought  to  be  worn  for  some  months. 
The  junior  surgeon  may  be  warned  that  a  hard  swelling  about  the  testicle 
usually  persists  for  a  few  weeks  after  healing  which  may  alarm  the  patient 
unless  he  is  warned  of  the  possibility  before  hand. 


627 


PART  v.— THE  SPINE, 


CIL\PTER  LVL 

OPERATIONS  ON  THE  SPINE. 

It  is  important  to  recognize  certain  easily  remembered  relations  which 
exist  between  the  spinal  cord  and  the  spinous  processes.  These  relations  are 
thus  described  by  Chipault: 

(a)  The  terminal  cul-de-sac  of  the  dura  mater  corresponds  to  the  fifth  lum- 
bar interspinous  space. 

(b)  The  inferior  limit  of  the  spinal  cord  is  situated  in  men  at  the  level  of  the 
first,  in  women,  of  the  second,  in  infants,  of  the  third,  lumbar  spinous  process. 

(c)  The  cervical  segment  of  the  cord  terminates  at  the  level  of  the  sixth 
cervical  interspinous  space;  the  dorsal,  at  the  ninth  dorsal;  the  lumbar,  at  the 
inferior  border  of  the  twelfth  dorsal  spine;  the  sacral  segment  ends  at  the  su- 
perior border  of  the  first  lumbar  spine. 

(d)  The  relations  of  the  summits  of  the  spinous  processes  to  the  nerve  roots 
may  be  expressed  by  a  simple  formula  which,  while  not  mathematically  correct, 
is  suflaciently  so  to  act  as  a  guide  in  surgical  intervention. 

For  adults  the  formula  is:  In  the  cervical  region  to  find  the  nerve  which 
emerges  at  the  level  of  the  individual  spinous  process,  add  the  numeral  one  to 
the  number  of  the  process,  e.  g.,  it  is  the  third  cervical  root  which  emerges 
opposite  the  second  spinous  process.  In  the  superior  dorsal  region  add  the 
numeral  two  to  the  number  of  the  process.  From  the  sixth  to  the  eleventh 
dorsal  processes  add  the  numeral  three.  The  inferior  part  of  the  eleventh 
dorsal  spinous  process  and  the  subjacent  interspace  correspond  to  the  origin  of 
the  sacral  nerves. 

For  children  under  the  age  of  six  or  seven  years  the  following  modification  of 
the  formula  holds  good:  In  the  superior  dorsal  region  (from  the  first  to  the 
fourth  apophysis)  add  three  to  the  number  of  the  spinous  process  to  obtain  the 
number  of  the  corresponding  nerve  root;  in  the  mid-dorsal  region  (fifth  to  ninth 
apophyses)  add  the  numeral  four. 

LUMBAR  PUNCTURE. 

Lumbar  puncture  is  the  operation  by  which  the  lumbo-sacral  cerebro- 
spinal cistern  is  tapped. 

Objects  of  the  operation,  (a)  Diagnostic:  Observation  of  the  tension,  the 
chemical  composition,  the  freezing  point,  the  cellular  composition,  the  bacteri- 
ology of  the  fluid  and  the  permeability  of  the  meninges  to  chemical  substances 

629 


630 


OPERATIONS    OX    THE    SPINE. 


Ill 


VII 


IX 


XI 


W 


W 


introduced  into  the  blood,     (b)  Therapeutic:     Relief  of  cerebro-spinal  tension. 
(c)  A  step  in  the  production  of  spinal  anaesthesia. 

One  must  remember  that  there  is  no  means  of  knowing  whether  the  fluid 
obtained  by  puncture  in  any  individual  case  is  from  the 
subarachnoid  or  the  subdural  space  (Ballance). 
^[-l  "^  "  The   commonest  site  for  the  puncture  is  between 

fourth  and  fifth  lumbar  vertebrae,  though  Chipault 
thinks  the  lumbo-sacral  space  better  as  it  is  larger, 
surrounded  by  good  landmarks  and  is  opposite  the 
terminal  enlargement  of  the  dural  sheath:  Puncture  in 
fourth  lumbar  interspace. 

It  will  be  most  convenient  to  describe  the  operation 

_1\  as  performed  for  the  production  of  spinal  anaesthesia. 

Step   I. — Seat  the  patient  with  his  legs  and  arms 

hanging  in  front  and  body  bent  well  forwards.     Clean 

the  whole  lower  part  of  the  back.     Palpate  the  crest  of 

the  ihac  bones;  note  their  high  points;  join  these  points 

by  a  line.     This  line  bisects  the  fourth  lumbar  space 

"      (Figs.  732,  733,  Marion).       Place  and  keep  a  finger  on 

the  point  of  the  fourth  lumbar  spine. 

Step  2. — Take  a  hollow  needle  about  3  inches  long 
and  about  1/32  inch  (i  mm.)  in  diameter.  Probably 
Dawbarn's  is  the  best  needle.  Introduce  the  needle 
about  3/4  inch  from  the  middle  line  and  slightly  below 
the    spinous    process.      Push    the    needle    slowly    and 


Fig.    731. — {Poirier 
and  C harpy.) 


Fig.  -■ 


-{Marion.) 


steadily  forwards  and  sKghtly  inwards  until  the  cerbro-spinal  fluid  escapes 
drop  by  drop.  If  the  operation  is  performed  for  diagnosis  or  relief  of  tenison 
collect  the  fluid  in  a  sterile  test-tube.  In  children  the  needle  must  usually 
penetrate  i  to  i  1/4  inches,  in  adults  i  1/2  2  1/2  inches  or  more. 


MENINGITIS. 


631 


Step  3. — As  soon  as  the  liquid  begins  to  escape  fix  a  hypodermic  syringe  to 
the  needle.  The  syringe  should  contain  the  sterilized  powder  to  be  injected 
(tropacocain ;  stovain;  novocain).  Slowly  withdraw  the  piston  of  the  syringe 
and  thus  draw  cerebro-spinal  fluid  into  the  syringe.  As  soon  as  the  fluid  has 
dissolved  the  powder  reinject  slowly.  Remove  the  needle.  Dress  the  puncture 
wound  with  collodion.  The  operation  may  be  performed  with  the  patient  in 
the  lateral  posture,  lying  down  with  the  back  thoroughly  flexed. 

The  author  has  had  no  personal  experience  with  spinal  anaesthesia. 


Fig.  733. — {Marion.) 


SPINAL  MENINGITIS. 

The  operative  treatment  of  spinal  meningitis  is  in  its  infancy.  A  case  re- 
ported by  Kiimmel  ("Archiv  fiir  klin.  Chir.,"  Ixxvii,  938)  gives  hope  for  the 
future.  A  sacral  tumor  had  been  removed  from  a  woman,  aged  twenty-seven; 
a  fistula  resulted  and  became  infected;  an  extensive  pelvic  phlegmon  formed; 
the  patient  became  very  restless  and  stupid,  later  comatose.  Pulse  160.  Temp. 
105°.  Cerebro-spinal  meningitis  was  clearly  present.  By  lumbar  pimcture 
there  was  drawn  off  cloudy  punflent  fluid  which  was  under  pressure.  In 
spite  of  the  desperate  condition  of  the  patient,  the  spinal  canal  was  opened  from 
the  fistula  up  to  the  second  lumbar  vertebra;  bad-smelling  pus  escaped;  the 
discolored  dura  was  widely  opened;  the  arachnoid  was  injected  and  infiltrated 
with  pus. 

The  patient  regained  consciousness,  headache  disappeared,  vomiting  ceased, 
spinal  rigidity  almost  vanished.  Ovvdng  to  extreme  weakness  the  patient  died 
within  forty-eight  hours.  The  autopsy  showed  extensive  suppurative  cerebro- 
spinal meningitis;  pelvic  phlegmon  and  peritonitis;  pericarditis.  This  case, 
in  spite  of  its  fatal  outcome,  is  encouraging. 

Murphy  formulates  the  indications  for  operative  intervention  in  acute 
meningitis  as  follows: 


632  OPERATIONS    ON   THE   SPINE. 

"i.  Lumbar  spinal  puncture  for  the  diagnosis  as  well  as  for  the  relief  of 
cerebro-spinal  tension.  Large  quantities  of  fluid  may  be  withdrawn  at  in- 
dividual sittings  in  this  way,  and  the  sittings  may  be  as  frequent  as  the  symptoms 
of  cerebral  pressure  recur.  A  cannula  with  a  double  opening  at  its  lower 
end  may  be  substituted  for  the  needle  in  cases  of  rapidly  recurring  cases  of 
hyperpressure.  This  must  be  very  cautiously  protected  against  the  entrance 
of  air  and  micro-organisms. 

"2.  Continuous  drainage  of  the  spinal  canal  with  secondary  drainage  of 
the  ventricles  may  be  established  by  a  single  laminectomy  with  the  insertion  of 
a  very  small  tube.  This,  however,  will  be  rarely  indicated  if  the  cannula  is 
used  judiciously  and  to  its  best  purpose. 

■  "3.  Ventricular  drainage,  transoccipital,  can  be  made  through  a  musculo- 
cutaneous flap  with  a  trephine  opening  in  the  occipital  bone  to  the  right  or 
left  of  the  median  line,  an  inch  posterior  to  the  foramen  magnum.  The  dura 
may  then  be  excised,  the  bony  opening  enlarged,  if  necessary,  with  bone- 
forceps,  the  velum  exposed,  opened  if  indicated,  or  the  tube  may  be  inserted  in 
the  subarachnoid  space  without  opening  the  velum.  This  can  be  utilized  in 
connection  with  spinal  puncture  or  laminectomy. 

"4.  Transparietal  ventricular  drainage  can  be  established  by  following 
the  description  given  in  the  average  work  on  surgery  for  the  insertion  of  the 
tube  into  the  lateral  ventricles.  A  small  trephine  opening  is  all  that  is  necessary 
for  this  procedure.  It  is  an  operation  that  will  be  rarely  undertaken,  as  lateral 
ventricular  is  the  least  common  of  the  meningeal  infections.  The  duration  of 
the  drainage  is  governed  by  the  general  surgical  principles  of  drainage.  I 
prefer  rubber  to  the  metallic  type  of  drain." 

Operation  for  Acute  Lepto-meningitis. — Drainage  and  Spinal  Irrigation. 
— ^Place  the  patient  in  a  position  with  maximum  flexion  of  the  lumbo-sacral 
region. 

Step  I. — Make  a  three-inch  longitudinal  incision  on  each  side  of  the 
sacrum,  following  the  lines  of  the  postero-external  tubercles.  Unite  the 
lower  ends  of  the  incision  by  a  curved  transverse  cut  at  the  level  of  the  last 
sacral  tubercles.  Reflect  upwards  the  U-shaped  flap  until  the  sacral  foramina 
•are  exposed. 

Step  2. — With  bone-forceps  divide  the  sacral  laminae  from  below  upwards 
until  the  dura  is  exposed  at  the  third  body.  This  portion  of  the  dura  forms  the 
lower  boundary  of  sacral  cerebro-spinal  cistern.     Attend  to  haemostasis. 

Step  3. — Make  a  small  longitudinal  incision  through  the  dura.  Permit  the 
escape  of  enough  fluid  to  relieve  tension.  Close  the  dural  wound  with  a  hem- 
ostat.     Temporarily  cover  the  wound  with  dressings. 

Step  4. — Make  an  incision  parallel  to  and  below  the  occipital  ridges  on  one 
side  down  to  the  bone.  From  the  inner  end  of  this  incision  make  a  median  cut 
downwards  to  within  1/2  inch  of  the  foramen  magnum.  Reflect  the  soft 
parts.     Open  the  skull  near  the  middle  line  over  one  cerebellar  fossa. 

Step  5. — Make  a  small  opening  through  the  dura  into  the  cerebellar  cistern. 


LAMINECTOMY. 


633 


Introduce  a  blunt  cannula,  such  as  is  used  in  the  intravenous  infusion  of  salt 
solution.     Attach  an  irrigator  charged  with  salt  solution  to  the  cannula. 

Step  6. — Remove  the  forceps  from  the  dural  opening  at  the  sacrum.  Permit 
salt  solution  to  flow  through  the  can- 
nula into  the  subdural  space,  through 
the  spine  and  out  through  the  sacral 
wound.  To  demonstrate  that  the  salt 
solution  introduced  above  is  escaping 
below  Murphy  suggests  coloring  it 
with  carmine. 

Step  7. — Insert  rubber  drainage- 
tubes  into  both  the  upper  and  lower 
openings.  Close  the  wounds  around 
the  tubes.  Regulate  the  cerebro-spinal 
tension  by  clamps  applied  to  the  tubes. 

Murphy,  who  has  systematized  the 
above  operation,  writes:  "The  irri- 
gation may  not  be  needed,  as  a  simple 
drainage  with  relief  of  pressure  or  pus 
tension  is  often  all  that  is  needed  to 
conduct  to  a  cure.  It  is  the  tension 
that  favors  absorption  and  tissue 
necrosis,  and  tiding  over  the  primary 
acute  pressure  of  the  products  of  in- 
fection is  life-saving." 

LAMINECTOMY. 

Laminectomy  is  the  operative 
means  by  which  the  spinal  canal  is 
opened  for  exploratory  or  therapeutic 
purposes. 

Method  A. — Step  i. — Make  a  verti- 
cal median  incision  over  the  spinous 
processes.  This  cut  reaches  directly 
to  the  spinous  processes,  and  is  at 
least  four  inches  in  length. 

Step  2. — On  one  side  of  the  spine 
separate  by  sharp  and  blunt  dissection 
the    muscles    from    the   side  of   the 

spinous  processes  and  from  the  back  of  the  laminae  of  the  vertebrae.  Bleeding 
is  usually  severe.  Quickly  pick  up  the  bleeding  vessels  with  forceps  and 
pack  the  wound  with  gauze  wrung  out  of  very  hot  water.  Separate  the 
muscles  on  the  opposite  side  in  the  same  way. 


Fig.  734. — {Murphy 
after  Poirier.) 


634 


OPERATIONS    ON   THE    SPINE. 


Improper  line 
of  division. 


Proper  line 
of    division 


Step  3. — Choose  the  point  at  which  to  enter  the  spinal  canal.  Divide  the 
interspinous  ligament.  Cut  away  the  spinous  processes  with  bone-cutting 
forceps.  Proceed  to  the  division  of  the  laminae  for  which  several  methods  are 
available:     (a)  Apply  an  osteotome  to  the  lower  edge  of  the  lamina  and  with 

blows  of  a  mallet  drive  it  through  the 
bone.  It  is  important  to  keep  the  long 
axis  of  the  osteotome  parallel  to  the  plane 
of  the  bone  lest  the  instrument  penetrate 
and  injure  the  contents  of  the  canal.  It 
is  also  important  to  have  the  bone  incision 
at  right  angles  to  the  lamina,  otherwise 
the  instrument  may  cut  its  way  into  the 
pedicle  of  the  vertebra  and  much  time  be 
lost  (Fig.  735).  Having  divided  one 
lamina  divide  the  lamina  on  the  opposite 
side  of  the  same  vertebra  and  remove  the 
bone.  The  laminae  of  the  vertebrse  above 
and  below  may  be  divided  as  required 
with  osteotome  or  with  forceps. 

(6)  Perforate  a  lamina  with  a  Doyen 
burr  or  with   a  trephine  and  complete 
its  division  with  forceps  (Keen's;    "De 
Vilbiss,"   etc.). 
(c)  Divide  the  laminae  with  a  saw.     (Hay's,"  MacEwen's,  Doyen's.") 
Step  4. — Inspect  carefully  the  contents  of  the  spinal  canal.     Examine  the 
anterior   as  well  as  the  posterior  surface  of  the  cord.     The  cord  may  be 
gently  pulled  to  one  side  without  damage  resulting.     Note  the  condition  of  the 
posterior  surface  of  the  vertebral  bodies. 
Carry  out  any  therapeutic  measures 
which  may  be  indicated.      If  it  seems 
necessary  to  open  the  dura  mater,  do  so, 
and  close  the  opening  with  fine  catgut 
sutures.     Having  completed  the  explora- 
tion or  whatever  operative  measures  may 
have  been  necessary,  close  the  external 
wound  by  deep  and  superficial  sutures, 
with   or   without   drainage.      Generally 
drainage    during    the    first    twenty-four 
hours  is    advisable.      Apply   the   usual 

dressings  and  carry  out  subsequent  treatment  on  the  ordinary  principles  of 
surgery. 

Method  B. — Fraziefs  Method. — To  increase  insurance  against  infection  and 
to  arrest  promptly  the  flow  of  cerebrospinal  fluid  when  the  meninges  have  been 
opened  Frazier  divides  the  skin,  fascia  and  muscles  in  different  planes. 


Fig.  735. 


Fig.  736. 


LAMINECTOMY. 


635 


Step  I. — Reflect  a  skin  flap,  A  B  C  D  (Fig.  736),  so  as  to  expose  the  desired 
area. 

Step  2. — Make  a  vertical  incision  through  the  aponeurosis  a  little  to  one 
side  of  the  median  line  and  by  reflecting  the  aponeurosis  slightly  from  the 
deeper  structures  gain  access  to  the  muscles  on  each  side  of  the  spinous  processes. 

Step  3. — Separate  ihe  muscles  from  the  spinous  processes  and  laminae  in 
the  usual  manner. 

In  closing  the  wound  suture  the  different  structures  separately. 


Fig.  737. — {Urban.)     (Archiv.  fiir  Klin.  Chir.J 
a,  Divided  laminae;  b,  post,  wall  of  spinal  canal  reflected  in  flaps;  c,  cord. 


Method  C. — Urban's  Osteoplastic  Method. — Make  a  U-shaped  incision 
around  the  area  of  spine  to  be  attacked.  Through  the  vertical  limbs  of  the  U 
expose  and  divide  the  vertebral  laminae  with  chisel,  saw,  or  forceps.  Divide 
the  interspinous  ligament  opposite  the  transverse  part  of  the  U  cut.  Expose 
the  spinal  canal  by  reflecting  the  U-shaped  flap  which  contains,  besides  the 
skin  and  soft  structures  of  the  back,  the  spinous  processes  and  part  of  the 


636 


OPERATIONS    ON   THE   SPINE. 


vertebral  laminae.  (Fig.  737.)  The  rest  of  the  operation  is  the  same  as  in 
Method  A. 

Method  D. — Abbe's  Osteoplastic  Method. — Make  an  incision  through  the 
soft  parts  about  1/2  inch  to  the  side  of  the  spinous  processes.  Expose  one  side 
of  the  spinous  processes.  With  a  chisel  or  osteotome  divide  the  spinous  pro- 
cesses near  the  laminae.  Turn  the  spines  back  along  with  the  soft  parts  as  a 
flap  on  the  other  side  of  the  wound.     Proceed  with  the  laminectomy. 

Method  E. — Rbpke's  Temporary  Laminectomy. — ("  Zentralblatt  fur  Chir.," 
1910,  No.  33.) 

Step  I. — Make  a  longitudial  incision  over  the  spinous  process  of  the  selected 
vertebrae.  Separate  the  soft  parts  on  each  side  from  these  processes  and  down 
to  their  bases.  Remove  each  spinous  process  by  cutting  it  at  its  base  with  a  bone 
forceps. 


Fig.  738. 


Fig.  739. — {Marion.) 


Step  2. — With  a  wide  chisel  applied  to  the  osseous  wound  cut  off  a  slice  of 
each  lamina  (Fig.  738)  and  retract  these  mobilized  portions  of  laminae  along 
with  the  soft  parts. 

Step  3. — With  a  chisel  or  rongeur  forceps  excise  the  remaining  portions  of 
the  laminae.  This  gives  free  access  to  the  spinal  cord.  Ropke  in  one  case  was 
able  to  remove  two  tumors  from  the  sides  of  the  cord  and  one  from  inside  the 
cord  itself. 

Step  4. — After  completing  the  operation  on  the  cord  and  suturing  the  dura, 
replace  the  bone- periosteal  flaps  and  close  the  wound  with  sutures. 

To  the  author  it  seems  that  Ropke's  operation  will  prove  useful  in  cases  of 
tumor  of  the  cord  and  where  divisions  of  the  posterior  nerve  roots  is  indicated 
(Foerster's  operation). 

Method  F. — Osteoplastic  Method  of  Cavicchia  and  Durante. — This  method, 
very  similar  to  Abbe's  is  most  highly  recommended  by  Marion. 

Step  I. — Make  a  slightly  curved  incision  (Fig.  739,)  to  oudine  a  skin 
flap  which  when  reflected  will  expose  the  region  to  be  attacked.  As  in 
craniectomy  it  is  necessary  to  open  the  spine  widely  to  avoid  missing  the  lesion 
present.  A  minimum  of  four  arches  ought  to  be  opened  except  in  cases  of 
localized  osseous  lesions;  hence  a  large  skin  incision  is  necessary."  (Marion.) 


LAMINECTOMY. 


637 


Step  2. — Leaving  the  supra-  and  interspinous  ligaments  intact,  separate  the 
soft  parts  on  each  side  from  the  spinous  processes  and  laminEe.  Retract  the 
soft  parts.  With  the  chisel  as  in  Abbe's  operation  divide  the  bases  of  the  spines 
or  do  the  same  thing  by  means  of  special  forceps  (Fig.  740).  Retract  the  line 
of  mobilized  spinous  processes  which  remain  attached  to  each  other  and  to  the 
body  by  the  supra-  and  inter-spinous  ligaments. 


Step  3. — As  in  Method  A.  When  the  wound  is  closed  the  chain  of  spinous 
processes  is  left  in  place  and  is  believed  to  give  support  to  the  back. 

To  the  author  is  seems  that  the  simplest  manner  of  opening  the  spine  is  the 
best.  The  loss  of  the  laminae  of  four  vertebras  does  not  seem  to  appreciably 
lessen  the  stability  of  the  spine. 


638  OPEIL\TIONS    ON    THE    SPINE. 

tubp:rculous  paraplegia. 

A  tuberculous  lesion  situated  in  the  body  of  a  vertebra  (usually  lower 
dorsal  or  upper  lumbar)  may  spread  backwards  and  form  a  tuberculoma  which 
presses  on  the  Jront  of  the  cord.  The  cord  is  usually  bent  and  flattened  but 
for  a  long  time  there  may  be  no  trophic  or  degenerative  changes  in  the  cord. 
In  a  case  favorable  for  operation  the  disease  is  practically  an  extra  dural  tumor 
on  the  posterior  surface  of  the  vertebral  body  and  hence  the  early  paraplegic 
symptoms  are  purely  motor.  Operation  is  indicated  before  degeneration  of  the 
cord  becomes  established  and  after  proper  treatment  by  hygiene  and  im- 
mobilization has  failed.  According  to  Gowers  paralysis  due  to  vertebral 
caries  is  the  most  favorable  of  all  types  of  paralyses. 

Operative  Treatment. 

Step   I. — Open  the  spine  by  laminectomy.     Do  not  open  the  meninges. 

Step  2. — Displace  the  cord  to  one  side.  Expose  the  granuloma  and  thor- 
oughly remove  it  with  the  curette.  Dry  the  bone  cavity  carefully  and  fill 
it  with  a  Mosetig-Moorhof  bone  plug. 

[Iodoform,  60;  spermaceti  and  oleum  sesami,  aa,  40;  heated  slowly  to 
100°  C.  in  a  flask  on  a  water-bath;  kept  at  this  temperature  for  fifteen  minutes, 
then  removed  and  allowed  to  cool  and  solidify,  while  shaken  constantly. 
Before  using,  melt  and  heat  to  50°  C.  in  a  thermostat.] 

If  the  wound  heals  without  suppuration  and  operation  has  not  been  too 
long  delayed,  the  paraplegia  rapidly  disappears. 

Harte  ("Trans.  Am.  Surg.  Assoc,"  1905)  has  collected  records  of  ninety-two 
operations  for  spinal  tumors  with  a  total  mortality  of  47  per  cent. ;  the  mortality 
due  to  the  operation  was,  however,  only  28  per  cent.  Even  when  a  cure 
could  not  be  obtained  relief  from  pain  was  almost  always  secured.  The 
large  number  of  sarcomata  removed  and  the  striking  absence  of  recurrence 
exhibited  (seventeen  out  of  thirty-seven)  makes  it  probable  either  that  there 
was  a  mistake  in  the  histologic  diagnosis  or  that  sarcomata  in  this  region  are 
of  comparative  benignity. 

In  some  of  Harte's  cases  the  symptoms  of  tumor  were  due  to  meningeal 
thickenings  or  adhesions.  In  the  discussion  of  Harte's  paper  J.  C.  Munro 
stated:  "  In  a  number  of  cases  that  I  have  had — cases  of  syringomyelia  and 
of  chronic  fracture — I  have  found  that  which  at  one  time  was  denied  by  patholo- 
gists, a  definite,  localized  collection  of  clear  fluid  in  the  subarachnoid  space 
which  produces  by  its  pressure  more  or  less  complete  paralysis.  By  open- 
ing this  small  sac  of  fluid  the  symptoms  may  be  absolutely  relieved." 
These  remarks  of  Munro's  are  quoted  here  because  they  bear  out  remarkably 
some  observations  of  F.  Krause  (Proceedings,  "German  Surg.  Soc,"  1907). 
Krause  has  opened  the  spinal  canal  twenty  times  for  tumor-like  symptoms, 
and  has  found  tense  subdural  collections  of  fluid  eight  times.  On  section  of 
the  dura  the  fluid  forced  itself  out  and  the  arachnoid  protruded  in  bladder- 
like manner  through  the  dural  wound.     Adhesions  existed  between  the  dura 


INJURIES    TO   SPINE.  639 

and  the  pia.  The  disease  is  a  local  collection  of  fluid  in  the  arachnoid  and 
has  been  named  meningitis  serosa  spinalis.  The  results  obtained  from  evacu- 
ation of  the  fluid  and  closure  of  the  wound  have  been  good. 

In  operating  for  tumors  one  must  remember  the  tendency  to  locate  the 
tumors  at  a  lower  level  than  that  at  which  they  actually  exist  and  that  there- 
fore, if  no  growth  is  found  on  opening  the  spine,  one  should  remove  the  laminae 
of  one  or  two  higher  vertebrae. 

TUMOR  OF  THE  SPINAL  MENINGES. 

Expose  the  spinal  canal  by  Method  A.  If  the  tumor  is  external  to  the 
meninges  extirpate  it,  being  careful  to  avoid  injury  to  the  nerve  roots.  If 
any  nerve  leaving  the  cord  is  divided,  it  should,  if  possible,  be  immediately 
reunited  by  suture.  The  posterior  surface  of  the  meninges  is  generally  sep- 
arated from  the  bone  by  a  collection  of  fat  containing  many  veins;  thus  hem- 
orrhage may  be  troublesome,  but  this  can  be  readily  stopped  by  packing  with 
strips  of  gauze  wrung  out  of  very  hot  water.  When  the  tumor  is  inside  the 
dura,  that  membrane  must  be  divided,  the  limits  of  the  growth  defined,  and 
its  removal  effected  by  carefvd  blunt  dissection.  After  attending  to  hemosta- 
sis  the  wounded  dura  may  be  sutured  or  not,  according  to  indications. 

Tumors  of  the  cord  itself  are  not  amenable  to  surgical  treatment. 

INJURIES  TO  THE  SPINE. 

It  is  extremely  difficult  to  lay  down  precise  rules  for  guidance  as  to  when 
and  when  not  to  operate  in  injuries  of  the  spine  and  spinal  cord.  J.  B.  Murphy 
has  formulated  certain  guiding  principles,  of  which  an  abstract  is  here  given: 

A.  Paralysis  from  contusion  may  be  due  to  "traumatic  zonal  inflammation," 
may  have  no  initial  symptoms  and  may  only  develop  days  or  even  weeks 
after  the  injury.  Such  cases  are  more  liable  to  be  cured  without  than  with 
surgical    intervention. 

B.  When  immediately  Sihev  the  in]nry  there  is  unij'onnly  transverse,  complete 
paralysis  of  motion  and  sensation  operation  is  useless,  as  the  cord  is  completely 
divided  and  regeneration  is  impossible. 

C.  Fracture  of  the  spine  is  present,  but  there  is  no  great  displacement. 
Paralysis  appears  hours,  days  or  weeks  after  the  injury.  The  paralysis 
is  not  complete  and  annular  of  both  motion  and  sensation.  It  is  impossible 
to  diagnose  whether  the  cord  lesion  is  due  to  contusion  or  to  pressure.  Murphy 
advises  strongly  against  operation. 

D.  If  under  the  above  circumstances  (C)  there  is  marked  displacement 
it  is  proper  to  diagnose  compression,  and  immediate  operation  is  indicated. 

E.  Fracture  of  the  spine  is  present  below  the  twelfth  dorsal  vertebra.  The 
rules  given  above  no  longer  apply.  At  the  twelfth  dorsal  vertebra  the  spinal 
cord  ends  and  the  cauda  equina  begins. 


640  OPERATIONS    ON   THE    SPINE. 

"The  Cauda  equina,  which  begins  here,  is  made  up  of  essentially  per- 
ipheral nerve  fasciculi,  and  not  of  spinal  cord  fasciculi,  as  the  axones  of  the 
motor  root  in  this  portion  have  their  ganglion  trophic  cells  above  this  level 
in  the  conus,  and  the  motor  axones  in  the  cauda  are  covered  with  the 
sheath  of  Schwann,  or  neurilemma.  They  therefore  degenerate  after  division, 
and  have  the  power  of  regenerating,  the  same  as  peripheral  motor  axones. 
The  sensory  neurons  of  the  posterior  roots  of  the  cauda  have  their  ganglion 
cells  just  inside  the  sacral  and  lumbar  foramina.  Their  proximal  axones, 
which  run  through  the  cauda  to  the  spinal  cord  are  medullated,  and  have 
a  sheath  of  Schwann.  They  are  capable  of  regenerating,  at  least  up  to  the 
posterior  commissures,  and  from  clinical  observation,  we  believe,  can  again 
functionally  contact  with  the  posterior  horn  of  gray  matter.  In  other  words 
both  the  motor  and  sensory  neurones  in  the  cauda  outside  of  the  cord  are  his- 
tologically capable  of  regeneration  under  favorable  conditions;  that  is,  after 
accurate  suture  and  exact  approximation  of  the  ends  of  the  divided  caudal 
fasciculi  under  aseptic  conditions." 

Every  case  of  fracture  of  or  injury  to  the  spine  in  the  lumbar  region  ac- 
companied by  paraplegia  demands  operation.  Causes  of  compression  must 
be  removed;  divided  fasciculi  must  be  united  by  suture.  "It  is  easy  to  de- 
termine which  are  the  right  and  left  fasciculi  by  a  mild  faradic  current  up 
to  the  seventh  day  after  the  injury." 

F.  In  cases  of  bullet  wound  of  the  spine,  when  the  bullet  is  shown  by 
the  X-rays  to  be  inside  the  spinal  canal,  operation  is  demanded.  Other 
cases  of  bullet  wounds  of  the  spine  should  be  treated  by  the  rules  already 
laid   down. 

The  principles  or  rules  which  have  been  outlined  in  the  preceding  para- 
graphs are  those  given  by  Murphy  in  his  classical  monograph  ("  Surg.,  Gyn.  and 
Obstetrics,"  April,  1907)  and  are  the  outcome  of  large  experience  and  untir- 
ing study.  It  would  be  improper,  however,  to  omit  giving  the  opinions  of 
some  other  experienced  and  judicious  surgeons.  Chipault  advises  early 
operation,  except  when  functional  disturbance  is  very  slight  or  shock  is  very 
severe.  Reduction  by  extension  and  local  pressure  is  condemned,  as  such 
manoeuvres  are  very  liable  to  press  fragments  of  bone  into  the  cord  and  in- 
crease the  damage  immensely. 

A.  J.  McCosh  advocates  early  operation  before  there  is  time  for  secondary 
degenerations  to  become  established.  He  has  seen  good  follow  in  cases  where 
the  symptoms  pointed  to  total  transverse  lesions.  Mixter  and  Chase  have 
pointed  out  that  in  spite  of  the  absence  of  conduction,  normal  fibres  may  pass 
through  the  crushed  portion  of  the  cord.  Kocher  writes,  "If  one  has  had 
Munro's  experience,  that  out  of  thirty  cases  of  injury  to  the  upper  dorsal  and 
the  cervical  vertebrae  one  only  within  ten  years  lived  and  had  partial  restoration 
of  function,  while  in  the  same  period  of  time  operative  treatment  resulted  in 
three  complete  cures,  then  one  will  tend  to  advise  operation  in  every  case. 
The  cases  must  be  very  carefully  examined:  if  the  temperature  sinks  low  (as 


INJURIES   TO   SPINE.  64I 

is  often  the  case  in  high  lesions  of  the  cord)  no  operation  is  proper.  Munro 
lost  all  the  patients  on  whom  he  operated  for  acute  crushing  of  the  cervical 
cord.  It  remains  undoubtedly  true  that  we  must  diagnose  irreparable  total 
transverse  destruction  of  the  cord  in  the  great  majority  of  patients  who  exhibit 
sudden  and  complete  loss  of  motion  and  sensation  with  immediate  and  total 
loss  of  the  tendon  reflexes;  but  it  is  also  true  that  if  the  transverse  lesion  is  not 
total  then  remnants  of  sensation  are  present  from  the  first  or  appear  in  a  few 
hours  or  days." 

Jacobson  ("Operations  of  Surg.,"  ii,  1091  ed.  1908)  is  averse  to  any 
surgical  interference  in  cases  of  fractured  spine,  owing  to  the  amount  of  damage 
to  the  cord  being  usually,  from  the  first,  irreparable.  Thorburn  has  the  same 
opinion  as  Jacobson  regarding  fractures  above  the  level  of  the  first  lumbar 
vertebra;  regarding  fractures  below  this  level,  he  advocates  surgical  interference 
on  the  following  grounds: 

"  I.  We  may  here  expect  a  regeneration  of  the  nerve  roots,  the  physiological 
evidence  being  strongly  in  favor  of  such  regeneration,  and  not  against  it  as  in 
the  case  of  the  cord. 

"2.  The  absence  of  spontaneous  recovery  in  such  cases  in  itself  indicates 
the  presence  of  a  mechanical  obstacle,  such  as  permanent  compression  by 
bone,  blood-clot,  or  cicatrix,  otherwise  we  should  expect  the  roots  of  the  cauda 
equina  to  recover  as  other  peripheral  nerves  after  severe  injuries." 

Burrell  ("Trans.  Am.  Surg.  Assoc,"  1905)  studied  the  records  of  cases 
of  spinal  fracture  treated  in  the  Boston  City  Hospital  and  came  to  the  following 
conclusions: 

"  I.  That  fractures  of  the  spine  may  well  be  divided  into  two  classes:  first, 
fractures  of  the  spine  with  injury  to  the  cord;  and,  second,  fractures  of  the 
spine  without  injury  to  the  cord. 

"2.  That  it  is  not  best  to  decide  what  the  treatment  of  an  individual  case 
of  fracture  of  the  spine  should  be  from  the  statistics,  because  the  lesion  varies 
so  widely. 

"3.  That  in  many  cases  of  fracture  of  the  spine  it  is  impossible  to  primarily 
state  whether  the  cord  is  crushed  or  pressed  upon  by  bone,  blood,  or  exudate, 
except  by  an  open  operation. 

"4.  That  only  by  the  persistence  of  total  loss  of  reflexes,  complete  insensibil- 
ity to  touch  and  pain,  and  motor  paralysis  below  the  level  of  the  lesion  can 
total  transverse  destruction  of  the  cord  be  diagnosticated. 

"5.  That  if  pressure  on  the  cord  is  allowed  to  remain  for  many  hours, 
irreparable  damage  to  the  cord  may  take  place. 

"6.  That  unless  it  is  perfectly  clear  that  the  cord  is  irremediably  damaged, 
an  open  operation  to  establish  the  condition  of  the  cord  and  to  relieve  pressure 
is  imperative  as  soon  as  surgical  shock  has  been  recovered  from. 

"7.  That  in  certain  cases  of  fracture  of  the  spine,  when  the  cord  is  not 
injured,  but  is  liable  to  injury  from  displacement  of  the  fragments  of  a  vertebra, 
rectification  of  the  deformity  and  fixation  of  the  spine  may  be  used. 
41 


642  OPERATIONS   ON   THE    SPINE. 

"8.  That  if  the  cord  is  crushed,  no  matter  what  treatment  is  adopted, 
there  will,  of  necessity,  be  a  high  rate  of  mortality." 

Open  the  spinal  canal  by  Method  A.  Remove  all  blood-clot  and  severely 
damaged  tissues.  Stop  bleeding.  Examine  thoroughly  the  posterior  surface 
of  the  cord.  Examine  the  anterior  wall  of  the  spinal  canal.  If  there  are 
displacements  of  bone  in  this  location,  interfering  with  the  cord  or  lessening 
the  calibre  of  the  spinal  canal,  try  to  reduce  such  by  manipulations  under  the 
guidance  of  the  eye  and  finger.  If  manipulations  fail,  cut  away  such  pieces 
of  bone  as  threaten  the  integrity  of  the  cord  or  jut  into  the  canal.  This  may  be 
done  with  the  chisel  or  rongeur  forceps.  The  amount  of  bone  removed  may 
be  considerable.  Examine  the  cord  once  more.  If  it  does  not  pulsate  and 
presents  a  distended  and  bluish  appearance,  open  the  dura  and  clear  out  the 
blood-clot  which  will  be  found.  If  the  cord  is  flabby  and  small,  there  are 
probably  adhesions  existing  between  the  membranes  and  the  cord  or  between 
the  various  nerve  roots.  This  condition  calls  for  the  dura  to  be  opened  and 
the  adhesions  separated. 

Any  operation  undertaken  must  be  done  thoroughly.  The  wound  in  the 
dura  should  be  closed,  unless  this  is  contraindicated.  The  external  wound 
is  sutured  as  usual,  dressings  applied,  and  the  trunk  immobilized.  Harte 
and  Stewart  ("Trans.  Am.  Surg.  Assoc,"  xx)  report  the  case  of  a  woman 
twenty-six  years  of  age  who  was  shot  at  the  level  of  the  seventh  dorsal  vertebra. 
Operation  showed  that  the  spinal  cord  was  completely  severed,  a  gap  of  3/4 
inch  existing  between  the  segments.  After  removal  of  lacerated  and  frag- 
mented tissues  the  cord  was  united  by  three  chromicized  catgut  sutures. 
Sixteen  months  after  operation  "the  patient  voluntarily  flexes  the  toes,  flexes  and 
extends  the  thighs,  and  rotates  the  hips.  While  sitting  the  extended  leg  can 
be  raised  from  the  floor;  the  patient  can  slide  out  of  bed  into  her  chair  by  her 
own  efforts.  .  ,  .  The  bowels  move  every  second  day  and  are  vmder  perfect 
control,  excepting  the  presence  of  diarrhoea." 

SYRINGOMYELIA. 

J,  B.  Murphy  ("Surg.,  Gyn.,  Obstetrics,"  April,  1907)  writes: 
"While  neuropathologists  disagree  as  to  the  origin  of  syringomyelia, 
their  findings  are  uniformly  the  same.  Examination  of  a  cord,  even  before  its 
section,  reveals  a  bulging  on  the  posterior  half  of  the  cord,  which  fluctuates  on 
palpation.  On  section,  one  or  several  cavities  are  found  extending  upwards 
and  downwards,  either  for  a  limited  distance  or  through  the  entire  cord  up  to 
the  bulb,  and  occasionally  involving  the  latter.  Primarily  tlie  cavity  is  more 
commonly  found  in  the  cervical  swelling  of  the  cord.  The  cavity  occupies, 
almost  invariably,  one  or  both  posterior  horns,  just  behind  the  commissure 
and  close  to  the  central  canal.  The  latter  is  not  necessarily  dilated,  and  in 
some  cases  is  so  contracted  that  it  is  almost  impermeable.  Again,  the  syrin- 
gomyelic cavity  may  communicate  with  the  central  canal  and  form  one  large 


foerster's  operation.  643 

cavity,  impressing  one  that  the  condition  might  be  a  primary  hydromyelia. 
The  tube  may  be  patent  or  may  be  subdivided  by  septa,  either  lengthwise 
or  laterally,  making  single  or  mutiple  cavities.  It  may  communicate  with 
the  fourth  ventricle  or  end  near  it  in  subarachnoid  space.  The  shape  of  the 
cavity  is  tubular  or  tringular,  and  it  is  lined  with  cylindrical  epithelium  similar 
to  that  of  the  centre!  canal. 

"It  seems  to  us,  from  a  theoretical  standpoint,  that  this  disease,  at  least 
in  its  circumscribed  form,  offers  a  field  for  surgical  intervention.  As  soon  as 
opportunity  presents  itself,  I  will  perform  a  subdural  drainage  with  an  inab- 
sorbable  seton  which  will  keep  a  permanent  communication  between  the 
syringomyelic  canal  and  subdural  space,  and  insure  an  equalization  of  pressure, 
which  should  stop  the  advancement  of  the  disease,  even  if  it  does  not  permit 
restoration  of  function  in  some  of  the  compressed  ganglion-cells  and  axones. 
This  operation  suggested  by  Murphy  is  along  the  lines  of  those  successfully 
performed  by  Sutherland  and  by  Ballance  in  the  treatment  of  hydrocephalus." 

Foerster's  Operation. — Operative  Treatment  of  Spasticity  and  Athetosis. 
Division  of  posterior  or  sensory  roots  in  spastic  paraplegia  and  in  the  crisis  of 
tabes.  Frazier  writes  ("Surg.,  Gyn.,  Obstet.,"  Sept.,  1910)  "If  we  admit 
that  spasticity  or  spastic  muscular  contractures  are  reflex  disturbances,  unre- 
strained by  cortical  impulses,  one  way,  if  not  the  only  way  of  controling  them, 
is  to  remove  at  least  one  link  in  the  chain  of  the  reflex  arc.  Naturally  the 
motor  portion  of  the  arc,  the  anterior  horns,  the  roots,  or  the  peripheral  nerves 
cannot  be  broken,  otherwise  the  limb  would  be  hopelessly  paralyzed;  for  the 
same  reason  the  sensory  nerves,  many  of  which  are  mixed  nerves,  must  be 
left  intact,  so  that  by  a  process  of  exclusion  there  remain  the  sensory  roots." 

Stubborn  cases  of  radiculitis  causing  various  distressing  symptoms  may 
be  suitable  for  Foerster's  operation. 

Division  of  the  posterior  roots  was  first  suggested  by  Spiller  in  1905  ("  Journ. 
of  Nervous  and  Mental  Diseases,"  May,  1905)  but  Foerster  seems  to  have 
pushed  the  matter  more  vigorously  and  reported  five  cases  of  his  own  in  which 
Tietze  operated.  (Foerster,  "Zeitschrift  fur  Orthop.  Chir.,"  xxii;  Mittheil- 
ungen  aus  "d.  Grenzgeb.  d.  Med.  und  Chier.,"  xx;  Tietze,  Mittheilungen 
aus  "d.   Grenzgeb.   d.   Med.   and  Chir.,"  xx.) 

A  number  of  different  methods  of  operating  have  been  devised  by  various 
surgeons.  Tietze  and  others  divide  the  operation  into  two  stages:  first,  per- 
forming laminectomy  and  some  days  later  opening  the  dura  and  completing 
the  work.  Undoubtedly  a  two-stage  operation  facilitates  the  finding  of  the 
posterior  roots  in  that  there  is  less  blood  to  obscure  Ihe  view,  but  bleeding  can 
be  well  controlled  by  pressure  with  pads  of  hot  gauze  against  the  spinal  muscles, 
and  by  packing  narrow  strips  of  gauze  between  the  dura  and  the  lateral  portions 
of  the  vertebrae  after  the  spinal  canal  has  been  opened.  Danger  from  in  fection 
is  distinctly  less  in  a  one-stage  than  in  a  two-stage  operation.  (For  Frazier's 
method  of  exposing  the  cord  see  p.  634)  To  distinguish  the  posterior  roots  it 
is  necessary  to  have  free  exposure  of  the  posterior  surface  of  the  cord;  if  blood 


644 


OPERATIONS    ON    THE    SPINE. 


obscures  the  view  it  ought  to  be  removed  by  gentle  douching  with  warm  salt 
solution  (Fig.  741). 

After  the  dura  is  opened  attempts  to  remove  blood  by  means  "of  sponging 
are  liable  to  do  much  damage  to  the  delicate  nerve  structures  exposed. 

How  many  and  which  of  the  posterior  roots  ought  to  be  divided? 

Frazier  writes:  "It  is  known  that  the  supply  of  each  muscle  or  group  of 
muscles  is  represented  in  most  instances  by  three  segments  of  the  cord  and 
by  as  many  roots  and,  according  to  the  observations  of  Sherrington,  the  cutane- 
ous nerve  supply  of  any  given  area  is  derived  from  at  least  three  roots.  Theo- 
retically we  plan  to  break  the  reflex  arc  of  the  muscles  involved,  by  cutting 
off  as  many  peripheral  stimuli  as  possible;  we  should  not,  however,  remove 


Spinous  proc. 


Epidural  space 


.  Dura 
Subarachnoid  space 


Spinal  ganglion 


Ant.  root. 


Fig.  741. — {P airier  and  Charpy.) 


every  source  of  sensory  stimulation,  otherwise  we  would  substitute  a  condition 
of  absolute  anaesthesia  and  flaccidity  for  one  of  spasticity.  In  selecting  the 
roots  to  be  sacrificed  it  is  necessary  obviously  to  remove  at  least  two  of  the 
three  possible  sources  of  sensory  stimulation,  or,  in  other  words,  two  of  the 
three  roots  from  which  a  given  group  of  muscles  derives  its  sensory  supply. 
The  following  table  gives  the  sensory  distribution  to  the  muscles  of  the  lower 
extremities: 

Flexors  of  the  thigh,  l^^^^J^^L^?)^ 

Extensors  of  the  thigh,  L5S1S2 

Adductors  of  the  thigh,  1^2^^^(L,^ 

Abductors  of   the   thigh,   LgS^Sj 

Exter.    rotators   of   the  thigh,    LgSjSg 

Int.  rotators  of  the  thigh,    LgL^LgSjSj 

Extensors   of    the    leg,    L2L3L4 

Flexors  of  the  leg,   LgS^Sj 


foerster's  operation.  645 

Dorsal  flexors,  foot,  L^LgS^ 

Plantar  flexors,  foot,  LjSjSj 

In  considering  an  operation  for  spastic  paraplegia  there  are  seven  roots  to 
be  considered,  namely,  the  five  lumbar  and  the  first  two  sacral  roots.  Accord- 
ing to  Foerster's  first  dictum  at  least  four  roots  should  be  sacrificed  and  he 
selected  for  the  lower  extremity  the  second,  third,  and  fifth  lumbar  and  the 
second  sacral,  leaving  intact  the  first,  the  fourth  lumbar,  and  the  first  sacral. 

"The  general  rule  has  been  not  to  remove  more  than  two  successive  roots. 
If  the  resvilts  of  some  of  the  operations  have  been  accurately  recorded  our 
\aews  regarding  the  senson,'  distribution  of  the  spinal  roots  may  have  to  be 
revised.  Thus  Taylor  in  one  case  resected  sLx  successive  roots,  from  the 
twelfth  dorsal  to  the  fifth  lumbar  inclusive,  on  one  side  with  full  retention  of 
sensation,  and  in  another  case  seven  successive  roots  from  the  fourth  cervical 
to  the  second  dorsal  inclusive,  without  loss  of  reflexes.  This  is  absolutely 
at  variance  with  our  present  conception  of  the  distribution  of  the  spinal  roots 
and  suggests  the  possibility  of  the  operator  having  left  some  fibres  undivided. 
The  difiiculty  in  separating  the  sensory  from  the  motor  roots  may  be  attributed 
to  the  inadequate  exposure  of  a  unilateral  opening. 

"  WTiether  or  not  it  may  be  possible  to  resect  a  series  of  five,  six,  or  seven 
successive  roots  without  permanent  disturbance  of  sensation  or  reflexes  in  a 
given  extremity,  it  is  unquestionably  true  that  the  desired  end  may  be  attained, 
the  spasticity  relieved,  by  resecting  four  out  of  seven  of  the  total  number  of 
roots  supplying  a  given  area.  Thus  in  one  of  Foerster's  cases,  one  of  Gottstein's, 
and  two  of  my  own  the  spasticity  was  relieved  by  resection  of  three  lumbar,  or 
three  lumbar  and  one  sacral  root. 

"  On  the  other  hand,  if  too  few  roots  are  resected  the  results  may  not  be  as 
satisfactory.  This  was  the  case  in  one  of  Foerster's  patients  where  he  resected 
only  the  third  and  fifth  lumbar  and  the  second  sacral,  and  in  one  of  my  own, 
where  although  four  successive  roots  were  resected — namely,  the  fifth,  sLxth, 
seventh  and  eighth  cervical — the  spasticit}^  was  only  partially  relieved. 
Therefore,  at  this  juncture  it  is  not  possible  to  lay  down  any  hard  and  fast 
rule,  sufiice  it  to  say  that  for  the  lower  extremity  perfectly  satisfactory  results 
have  been  obtained  after  resection  of  the  following  combinations: 

I.       LjLgL;, 

2.  L2L3L5S2,  or 

"For  the  upper  extremit}'  the  following  combination,  C^CgCgC-,  was  wholly 
eflfective  in  one  case  (Taylor's  third  case)  while  CjCgCjCg  only  partially  so  in 
another  (Frazier's  case). 

"We  may  conclude  from  this  that,  until  further  observations  are  made,  the 
fourth  cervical  should  be  included,  -^-ith  or  without  the  eighth." 

Immediately  after  operation  pain  and  spasticity  may  apparently  be  in- 
creased just  as  after  amputation  of  the  leg  severe  pains  are  experienced  and 
thought  to  be  in  the  foot  which  has  been  removed.     Soon  such  distressing 


646  OPERATIONS    ON   THE   SPINE. 

symptoms  decrease  and  disappear.  It  is  necessary,  however,  in  cases  of 
spasticity,  to  correct  deformities  which  have  become  established  and  to  institute 
well  regulated  muscular  exercises. 

Foerster's  operation  ought  to  be  reserved  for  severe  cases  of  spasticity  and 
of  the  crisis  of  tabes. 

The  published  results  have  been  good  and  the  death  rate  has  not  been 
very  high  considering  the  gravity  of  the  procedure. 

Hof man's  Method  of  Performing  Foerster's  Operation. — Temporary  Laminec- 
tomy.    (" Zentralblatt  fiir  Chir.,"  1910,  No.  20.) 

Step  I.  Make  an  incision  of  the  desired  length  over  the  spinous  processes  of 
the  vertebrae  to  be  reflected,  and  separate  the  musculature  by  blunt  dissection 
from  the  spinous  processes  and  from  the  laminae  on  both  sides  as  far  as  the 
lateral  processes.  The  sharp  bleeding  which  comes  from  the  muscles  is  easily 
controlled  by  gauze  pressure.     The  periosteum  has  not  been  injured. 

Step  2. — Divide  the  laminae  on  each  side  by  means  of  an  osteotome  held 
as  horizontally  as  possible. 

Step  3. — Divide,  transversely,  the  interspinous  ligament  either  above  or 
below  the  series  of  vertebrae  attacked,  according  as  the  bone  flap  is  to  be  re- 
flected downwards  or  upwards.  After  division  of  any"  remaining  connections 
reflect  the  flap  (consisting  of  periosteum,  spinous  processes,  laminae  and  inter- 
spinous ligaments)  upwards  or  downwards  as  may  be  desired.  The  dura  is  now 
at  least  partially  exposed  and  can  be  fully  exposed  by  nipping  away  some  more 
bone  with  rongeur  forceps.  If  the  chisel  is  properly  applied  Hofman  claims 
that  injury  to  the  dura  or  cord  is  hardly  possible.  This  claim  is  in  full  accord 
with  the  experience  of  the  late  D.  J.  Hamilton  who,  in  the  postmortem  room, 
similarly  exposed  innumerable  spinal  cords  without  injury  to  their  structure. 

Step  4. — Incise  the  dura  longitudinally  and  divide  the  desired  posterior 
spinal  roots. 

Step  5. — Close  the  dural  wound  by  a  continuous  suture. 

Step  6. — Replace  the  reflected  bone  flap.  Suture  the  muscles  and  fascia 
over  the  spinous  processes.     Close  the  skin  wound. 

Hofman  performed  the  above  operation  in  one  half-hour  which  would 
have  seemed  totally  incredible  to  the  author  had  he  not  known  of  Hamilton's 
remarkably  rapid  work  in  the  autopsy  room  to  which  reference  has  already 
been  made. 

(Further  information  regarding  Foerster's  operation  is  to  be  found  in  the 
discussion  before  the  German  Surgical  Association.  " Zentralblatt  fiir  Chir.," 
1910,  No.  31;  Codivilla,  "Muenchner  med.  Woch.,"  Ivii,  p.  1438;  Florcken, 
"Muenchner  med.  Woch.,"  Ivii,  p.  1441;  Bierens  de  Haan,  "Journal  de 
Chir.,"  Sept.,  1910.) 

SPINA  BIFIDA. 

To  understand  the  operative  treatment  of  spina  bifida  and  the  limitations 
thereof,  it  is  absolutely  necessary  to  have  clear  notions  as  to  its  pathological 


SPINA   BIFIDA. 


647 


anatomy.  The  usual  surgical  text-books  rarely  provide  such  notions,  hence 
the  author  will  try  to  describe,  very  briefly,  the  conditions  which  should  influence 
operation. 

A.  Meningocele. — A  defect  of  the  posterior  osseous  wall  of  the  spinal 
canal  is  present.  The  skin,  spinal  membranes,  and  cord  are  intact.  There 
is  a  hernia  of  the  dura  through  the  osseous  defect.  Fluid  in  greater  or  less 
quantity  is  present  in  the  dilated  subdural  space  (Fig.  742). 

B.  Meningocele. — The  conditions  are  the  same  as  in  A,  except  that  the 
arachnoid  is  involved  in  the  hernia  and  the  collection  of  fluid  is  in  the  sub- 
arachnoid space  (Fig.  743). 


SKIN 


Fig.  742. 


C.  Meningocele. — A  defect  exists  in  the  dura  as  well  as  in  the  bone. 
Through  these  defects  there  protrudes  a  hernia  consisting  of  the  arachnoid 
with  fluid  accumulated  in  the  subarachnoid  space.  The  skin,  pia,  and  cord 
are  intact. 

D.  Myelo-cystocele  (Fig.  744). — There  exists  a  defect  in  the  posterior 
osseous  wall  of  the  spinal  canal  and  also  in  the  corresponding  portion  of  the 
dura.  The  arachnoid  and  pia  are  intact.  The  central  canal  of  the  spinal 
cord  is  highly  distended  by  fluid,  so  that  a  hernia  is  formed  having  the  arach- 
noid and  pia  as  sac.  The  cord  substance  is  thinly  spread  out  over  the  inside 
of  the  sac — so  thinly  that  in  places  it  is  absent.  The  spreading  out  of  the  cord 
is  due  to  the  distention.  As  will  be  seen  by  reference  to  the  diagram,  nerve 
roots  run  forwards  in  the  hernial  sac.     This  is  of  importance  to  the  operator. 


648 


OPERATIONS    ON    THE   SPINE. 


E,  Myelocele. — A  defect  exists  in  the  skin,  in  the  posterior  osseous  wall 
of  the  spinal  canal,  and  in  the  corresponding  portions  of  the  dura,  arachnoid, 
and  pia.  The  posterior  surface  of  the  cord  itself  is  split  or  absent.  The 
central  canal  of  the  cord  is  open  to  the  air  (Fig.  745).  Fluid  collects  between 
the  pia  and  arachnoid  anterior  to  the  cord,  and  gives  rise  to  a  spinal  hernia. 
As  will  be  seen  by  referring  to  the  diagram,  skin  is  present  only  at  the  base 
of  the  tumor;  the  herinal  sac  consists  of  pia  mater  with  a  covering  of  cord  sub- 
stance. The  nerve  roots  run  from  the  cord  forwards  through  the  sac.  Shbuld 
a  collection  of  fluid  form  in  the  arachnoid  instead  of  in  front  of  it,  then  the 
arachnoid  will  form  part  of  the  hernial  sac  and  the  nerve  roots  will  run  forwards 
in  the  sac  wall. 


SKIN 


Fig.  744. 


ARACHNOID 
DURA 


Fig.  746. 


F.  Myelocele. — This  form  is  the  same  as  E,  except  that  there  is  no 
collection  of  fluid  (Fig.  746).  The  remnant  of  cord  substance  lies  in  a  groove 
or  depression  on  the  back  and  is  continuous  with  the  skin.  The  meninges 
are  continuous  with  the  subcutaneous  tissues. 

The  differential  diagnosis  of  myeloceles  E  and  F  is  easy.  They  are  in- 
operable. 

The  diagnosis  between  myelo-cystocele  D  and  meningoceles  A,  B,  and  C 
is  generally  impossible,  except  perhaps,  as  Horsley  has  suggested,  by  applying 
the  electric  current  and  observing  its  effects.  Myelo-cystoceles  are  more 
frequently  accompanied  by  other  deformities,  e.  g.,  club-foot,  exstrophy  of 
the  bladder,  etc.,  than  are  meningoceles.  The  fact  that  the  walls  of  a  myelo-cys- 
tocele contain  nerve  substance  while  those  of  meningoceles   do  not,   make 


SPINA   BIFIDA.  649 

positive  dififerentiation  between  the  two  forms  of  spina  bifida  indispensable 
for  scientific  treatment.  If  we  inject  a  solution  of  iodine  (Morton's  fluid) 
into  the  sac,  we  may  be  really  throwing  it  into  the  central  canal  of  the  spinal 
cord.  The  injection  of  iodine  has  been,  until  recently,  the  favorite  treatment 
for  spina  bifida,  but  in  view  of  the  facts  related  above  one  is  compelled  to  believe 
it  unscientific. 

Operation  is  contraindicated  in  cases  of  myelocele;  in  cases  of  spina  bifida 
accompanied  by  paralyses  or  contractures  evidencing  irreparable  defects 
in  the  cord  substance;  in  cases  of  severe  hydrocephalus  or  of  abdominal  or 
vesical   fistulae — in   all   other   cases   operation  is   proper. 

The  Operation. — Step  1. — Make  two  skin-flaps  from  the  base  of  the  tumor, 
of  sufficient  size  to  cover  the  wound  left  after  removal  of  the  sac.  These  flaps 
should  be  made  large  rather  than  small,  as  it  is  easy  to  trim  them  to  suit, 
before  applying  sutures. 

Step  2. — Having  exposed  the  sac  by  reflecting  the  skin-flaps,  make  an 
incision  into  it  on  one  side.  This  incision  should  be  made  transversely  and 
must  not  reach  to  the  middle  line  of  the  body  {i.  e.,  to  the  apex  of  the  tumor). 
The  reason  for  these  precautions  is  that  most  of  the  medullary  tissue,  if  present, 
is  situated  in  the  middle  line,  and  that  the  general  course  of  any  nerve  roots 
is  from  the  summit  of  the  sac  to  the  base,  i.  e.,  parallel  to  the  direction  of  the 
incision. 

Step  3. — Explore  the  sac  and  observe  whether  nerves  lie  free  in  it  (Fig. 
743)  or  are  enclosed  in  its  walls  (Fig.  742).  If  the  nerves  lie  free  in  the  sac, 
trace  them  to  their  point  of  origin  in  the  medullary  substance  which  forms 
part  of  the  sac.  Separate  the  medullary  substance,  and  such  of  the  sac  as  is 
united  to  it,  from  the  rest  of  the  sac  and  reduce  it  into  the  spinal  canal.  Remove 
the  excess  of  sac.  If  the  nerves  lie  in  the  sac  wall,  empty  the  sac  of  its  fluid 
and  reduce  it  en  masse  after  removing  all  skin  from  over  it.  If  the  case  be 
discovered  to  be  one  of  meningocele,  remove  the  whole  sac  after  suturing  its 
base. 

Step  4. — Close  the  wound  by  a  series  of  deep  and  superficial  sutures. 

Some  surgeons  have  recommended  that  the  osseous  defect  be  closed  by 
means  of  a  flap  of  bone  obtained  from  the  crest  of  the  ilium  and  provided  with 
a  pedicle.  This  procedure  must  rarely  be  indicated.* 

*  For  a  thorough  description  of  spina  bifida  and  its  operative  treatment  the  reader  is 
referred  to  Hildebrand'    article  in  the  "Archiv  f.  klin.  Chirurgie,"  Bd.  xlvi  H  ft  i. 


PART  VI.— UNCLASSIFIED  TOPICS. 


CHAPTER  LVII. 
ACUTE  ABSCESS. 


Acute  abscesses  ought  to  be  drained  as  early  as  possible  after  diagnosis. 
The  operation  should  be  performed  under  antiseptic  precautions.  This 
is  important  because  of  the  danger  of  causing  increased  or  mixed  infection, 
e.  g.,  grafting  a  streptococcic  on  to  a  staphylococcic  infection. 

Local  anaesthesia  is  usually  sufficient  to  prevent  suffering.  When  an 
abscess  is  superficial,  pass  the  knife  steadily  through  the  skin  and  subjacent 
tissues  until  pus  is  reached.  This  should  be  done  at  the  most  prominent 
or  most  dependent  part  of  the  swelling.  As  the  knife  is  withdrawn  the  wound 
may  be  enlarged.  A  good  guide  as  to  the  size  of  the  opening  to  be  made  is 
the  size  of  the  surgeon's  fingers.  In  a  small  and  not  deeply  situated  abscess 
the  little  finger  can  explore  the  whole  cavity;  in  larger  abscesses  the  index 
finger  must  be  used.  The  opening  should  be  made  of  sufl&cient  size  to  admit 
the  exploring  finger. 

When  the  abscess  is  deep,  Hilton's  method  of  operating  is  safe  and  excellent. 
An  incision  about  i  or  i  1/2  inches  in  length  is  made  over  the  most  prominent 
or  dependent  part  of  the  swelling.  The  incision  penetrates  the  skin  and  deep 
fascia.  A  grooved  director,  which  must  not  be  too  sharp,  is  insinuated  through 
the  tissues  in  the  direction  of  the  pus  until  pus  flows  along  its  groove.  The 
point  of  a  narrow-bladed  hemostat  or  blunt-pointed  scissors  is  passed  along  the 
director  into  the  abscess  cavity.  The  blades  of  the  instrument  are  now  opened 
and  made  to  dilate  the  opening  to  an  appropriate  size.  Frequently  counter- 
openings  are  required.  Such  may  be  made  by  passing  the  point  of  a  hemostat  into 
the  abscess  and  pushing  it  out  through  the  tissues  until  the  skin  is  reached.  The 
skin  elevated  by  the  point  of  the  forceps  is  divided,  the  blades  of  the  forceps 
are  opened  to  enlarge  the  passage,  a  drainage-tube  is  seized  by  the  forceps, 
and  as  the  instrument  is  withdrawn,  the  tube  is  pulled  into  position.  An 
abscess  having  been  opened,  its  cavity  ought  to  be  douched  thoroughly  with 
warm  water  or  a  mild  antiseptic  solution  until  the  solution  returns  clear. 
Any  gross  sloughs  or  masses  of  debris  should  be  removed  with  forceps,  finger, 
or  sharp  spoon.  The  last-named  instrument  should  not  be  used  too 
vigorously  lest  nature's  defense  against  absorption,  viz.,  granulation  tissue,  be  too 
thoroughly  removed,  or  violent  hemorrhage  or  persistent  oozing  started. 

651 


652  ACUTE   ABSCESS. 

Drainage-tubes  must  be  inserted  through  the  openings.  Young  practitioners 
often  deHght  in  the  use  of  tubes  about  the  size  of  a  crow-quill;  such  are  almost 
useless,  as  the  fluid  to  be  drained  is  thick  and  speedily  chokes  them.  Rubber 
tubes  which  vary  from  the  size  of  an  ordinary  lead-pencil  to  that  of  the  little 
finger  are  the  best;  no  object  is  to  be  attained  by  using  sizes  much  larger.  The 
external  end  of  the  tube  must  be  kept  from  slipping  into  the  wound,  either 
by  being  stitched  to  the  skin  or  by  having  a  large  safety-pin  passed  through  it. 

Bier  and  Klapp  obtain  excellent  results  by  merely  puncturing  the  abscess 
and  then  sucking  out  the  pus  by  means  of  cupping  glasses.  In  palmar  abscess 
this  treatment  is  specially  good.  The  suction  ought  not  to  be  vigorous  enough 
to  cause  pain;  it  ought  to  be  applied  for  five  minutes  and  left  off  for  two  minutes 
alternately,  for  about  forty-five  minutes  night  and  morning.  (Bier,  "Hyper- 
amie  als  Heilmittel.") 

J.  B.  Murphy  instead  of  opening  and  draining  abscesses,  aspirates  the  pus 
and  then  injects  formalin  glycerine.  (Formalin,  2;  glycerine,  98)  in  quantity 
sufiicient  to  produce  slight  tension.  The  solution  ought  to  be  kept  at  least 
24  hours  before  being  used.  If  a  tuberculous  bone  lesion  is  present  he  adds 
10  per  cent,  of  iodoform  to  the  above  mixture.  He  employs  this  treatment  in 
empyemata  of  the  chest  and  of  joints. 

Dressings. — Ordinary,  voluminous  antiseptic  dressings  must  be  applied 
in  such  a  manner  as  to  collect  the  discharge  and  at  the  same  time  exercise 
elastic  pressure  on  the  abscess  so  as  to  keep  it  collapsed  as  much  as  possible 
and  prevent  reaccumulation  of  fluid. 

PSOAS  ABSCESS. 

Treves'  Operation.^ — The  patient  is  placed  on  his  side  with  the  diseased 
side  uppermost.  Under  the  opposite  loin  there  is  placed  a  sand-bag.  An 
incision  2  1/2  to  3  inches  in  length  is  made  parallel  to  and  beside  the  outer  edge 
of  the  erector  spinas  muscle  {i.  e.,  about  3  inches  from  the  spinous  processes). 
The  middle  of  this  cut  corresponds  to  a  point  midway  between  the  last  rib 
and  the  iliac  crest.  The  dense  aponeurosis  covering  the  erector  spinae  is  di- 
vided throughout  the  whole  length  of  the  wound.  The  outer  edge  of  the  muscle 
is  demonstrated  and  then  strongly  retracted  towards  the  spine.  This  exposes 
a  layer  of  fascia  (middle  layer,  fascia  lumborum)  which  covers  the  quadratus 
lumborum.  By  palpation  find  the  transverse  processes  of  the  lumbar  vertebrae 
and  divide  the  fascia  as  close  to  them  as  possible.  The  thin  quadratus  lum- 
borum muscle  now  comes  into  view,  and  according  to  Treves  it  must  be  divided 
close  to  a  transverse  process.  The  next  tissue  met  is  the  psoas  muscle,  and 
when  some  of  its  tendinous  fibres  have  been  divided  close  to  a  transverse 
process,  the  finger  can  be  "introduced  beneath  the  muscle  and  gently  insinuated 
along  the  process  until  the  anterior  aspect  of  the  bodies  of  the  vertebne  is 
reached." 

Where  there  is  a  large  psoas  abscess  the  patient  is  almost  always  much 


ABSCESS. 


653 


emaciated  and  the  tissues  over  the  abscess  are  thin,  so  that  after  the  quadratus 
lumborum  muscle  has  been  exposed,  a  grooved  director  may  be  insinuated 
into  the  abscess  cavity  and  an  entrance  gained  by  Hilton's  method. 
Having  gained  access  to  the  abscess,  it  is  thoroughly  douched  with 
hot  water  or  a  hot  antiseptic  solution.  The  writer  often  uses  a 
sherry-colored  solution  of  tincture  of  iodine  in  hot  water.  The  lining 
membrane  of  the  abscess  is  to  be  scraped  away  with  finger-nail  and 
sponge  (Treves)  or  with  the  irrigating  curette  (Barker)  (Fig.  747). 
This  must  be  done  cautiously,  as  the  anterior  wall  of  the  abscess 
is  usually  thin.  All  pockets  leading  from  the  main  abscess  are 
explored  and  opened  up  by  the  finger.  All  accessible  portions  of 
the  spine  are  palpated,  and  if  any  tuberculous  nodules  are  found 
they  are,  if  possible,  to  be  removed.  Having  douched  and  cleaned 
and  douched  again,  until  the  fluid  returns  clear,  the  cavity  is  dried, 
two  or  three  ounces  of  iodoform  emulsion  are  thrown  into  it,  and 
the  wound  is  closed  without  drainage.  The  abscess  may  recur  and 
require  a  second  operation. 

The  after-treatment  consists  in  rest  under  hygienic  conditions, 
and  must  be  carried  out  for  many  months. 

The  great  advantage  of  the  Treves  operation  is  the  access  it 
gives  to  the  spinal  column — to  the  focus  of  the  disease. 

Should  the  abscess  have  opened  of  itself  in  the  thigh,  it  must 
be  treated  on  the  ordinary  surgical  lines,  i.  e.,  counteropenings  must  be  made 
to  provide  efficient  drainage. 


Fig.  747. 


CHAPTER  LVIII. 

METHODS  OF  DRAINAGE. 

The  collection  of  fluids  in  dead  spaces  in  wounds  is  potentially  dangerous, 
and  hence  drainage  should  be  provided  for  such  spaces.  Collections  of  pus 
or  other  noxious  fluids  in  any  part  of  the  body  require  removal,  usually  by 
means  of  drainage.  Drainage  in  its  simplest  form  is  exemplified  by  the  open 
treatment  of  wounds;  here  absorbent  dressings  are  applied  directly  to  the 
wound  surface  or  cavity  and  absorb  all  exuded  fluids  as  soon  as  secreted. 
Where  dressings  cannot  be  applied  directly  to  the  secreting  surfaces,  the 
secretions  must  be  guided  to  the  dressings.  According  to  the  nature  and  sur- 
roundings of  the  fluid  to  be  drained,  the  method  of  drainage  provided  must 


Fig.  748. 


Fig.  749. 


vary.  For  such  fluids  as  serum,  capillary  drains  sufl&ce;  for  thick  pus,  tubular 
drains  are  essential.  When  a  collection  of  pus  is  evacuated  through  the  per- 
itoneal cavity,  the  method  of  drainage  must  provide  protection  to  that  cavity, 
hence  a  combination  of  tubular  or  capillary  drainage  with  protective  packing 
becomes  necessary.     The  following  are  the  principle  means  of  drainage: 

A.  Capillary  Drains. — i.  Horse-hair;  silkworm- gut;  catgut.  A  few 
strands  of  these  materials,  in  a  bundle,  act  as  an  efficient  drain  for  small  quantities 
of  serous  exudates. 

654 


DRAINAGE. 


655 


Fig.  750. 


2.  Gauze  or  wick.  A  strand  of  absorbent  gauze  or  a  portion  of  lamp- 
wick  may  be  used  as  a  capillary  drain,  but  if  these  are  left  in  place  too  long, 
fluids  readily  coagulate  in  their  meshes,  and  instead  of  draining,  they  act  as 
a  plug  to  prevent  drainage. 

3.  Cigarette  drains  consist  of  gauze  surrounded  (Fig.  748)  by  a  sheet  of 
thin  rubber  tissue  which  enhances  their  efficiency  and  prevents  the  gauze 
becoming  adherent  to  surrounding  structures.  Instead  of  rubber  tissue  the 
gauze  may  be  surrounded  by  a  split  rubber  tube 
(Fig.  749).  Strands  of  woolen  yarn  are  more 
efficient  than  gauze. 

B.  Tubular  Drains. — i.  Rubber  tubes.  Very 
small  tubes  are  useless,  as  they  become  plugged  by 
coagulated  discharges.  The  most  useful  are  those  the  size  of  an  ordinary 
lead-pencil  or  of  the  little  finger.  It  is  rare  that  larger  tubes  are  necessary, 
and  then  only  in  the  form  of  split  tubes  covering  a  wick  of  gauze.  The 
tubes  must  be  perforated  laterally  and  their  distal  ends  should  be  trimmed  in 
a  fish-tail  fashion  (Fig.  750).  The  tube  may  be  prevented  from  slipping 
into  the  body  by  being  stitched  to  the  skin  or  provided  with  a  guard  in  the 
form  of  a  safety-pin. 

2.  Split  rubber  tubes  are  the  ordinary  tubes  split  up  one  side.  The  split 
renders  the  tubes  less  rigid  and  less  liable  to  cause  pressure  necrosis. 

3.  Dressed  drains  consist  of  a  rubber  tube  surrounded  by  a  few 
layers  of  absorbent  gauze  (usually  iodoform)  (Fig.  751)  the  gauze 
being  in  turn  covered  by  thin  rubber  tissue.  The  dressed  tube  is 
practically  a  cigarette  drain  with  a  tubular  core.  They  are  of 
great  value,  especially  in  abdominal  surgery. 

4.  Wetherill's  drain  is  useful  in  many  locations.  It  is  prepared 
as  follows: 

Cut  two  holes  in  a  long  piece  of  drainage  tubing  as  indicated 
at  A  and  B  (Fig.  752,  i).  Draw  one  end  of  the  tube  through  A 
and  out  at  B,  thus  inverting  that  portion  of  the  tube  between  the 
holes  as  seen  in  (Fig.  752,  2).  Bend  the  legs  of  the  tube  down  so 
that  the  holes  A  and  B  will  be  left  open  for  drainage  (Fig.  752,  3). 
If  bent  in  one  direction  they  are  open,  if  in  the  other,  closed. 
Tack  with  a  fine  stitch  at  C. 

5.  Rigid  tubes  of  glass,  hard  rubber,  celluloid,  etc.,  are  often 
employed.      These  may  be  provided  with  a  collar,  made  from  a 

of   rubber   tube,    through   which    a    safety-pin    or    stitch    may    be 
to    provide    (Fig.    753)    against    the    slipping  of  the  tube  into  the 


Fig.  751. 


segment 
inserted 
wound. 

C.  Combined  capillary  and  tubular  drainage  may  be  effected  by  sur- 
rounding any  of  the  ordinary  capillary  drains  with  a  tubular  drain,  e.  g.,  a 
rubber  tube  containing  a  bunch  of  silkworm-gut  threads. 

D.  Absorbable  Drains. — The  use  of  catgut  as  a  capillary  drain  has  already 


656 


METHODS    OF   DRAINAGE. 


been  noted.     Neuber  suggested  tubular  drains  of  decalcified  bone,  and  Mace- 
wen  introduced  the  inexpensive  chicken-bone  drain. 

Preparation  of  Chicken-bone  Drainage-tubes. — Clean  the  flesh  oflf  the  tibiae 
and  femora  of  chickens  (cooking  the  chicken  does  not  injure  the  bone).  Soak 
in  a  20  per  cent,  solution  of  hydrochloric  acid  until  soft.  Cut  off  the  articu- 
lar ends  of  the  bone  with  scissors.  Raise  the  endosteum  at  one  end  and  push 
it  through  to  the  other  extremity  along  with  its  contents.  Sterilize  by  boiling 
in  a  saturated  solution  of  ammonium  sulphate.     With  sterile  water  or  antiseptic 


\ 


-^^ 


Fig.  752. 


Fig.  753. 

solution  wash  off  the  sulphate  of  ammonium.  Preserve  in  alcohol  or  in  a 
solution  of  iodoform  in  alcohol  or  ether  and  alcohol.  These  tubes  last  for  about 
eight  days  in  the  tissues.  If  greater  durability  is  desired  {e.  g.,  when  they  are 
used  to  drain  cerebral  abscesses),  soak  in  a  sterile  solution  of  chromic  acid. 
Macewen  recommends  that  when  bone  drains  are  used  in  fresh  wounds 
they  be  threaded  with  horse-hair  to  prevent  plugging  with  clotted  blood  and 
to  encourage  capillary  drainage.  After  a  day  the  hairs  are  removed,  leaving 
the  tube  patent. 


CHAPTER  LIX. 
NERVES. 

NERVE  SUTURE;  NEURORRH.\PHY. 

Nerve  Suture. — A  few  words  on  the  repair  of  nerves  after  division  may  be 
forgiven  in  view  of  the  importance  of  understanding  some  of  the  possibilities 
of  operative  interference. 

The  older  doctrine  of  repair  was  that  after  division  the  whole  of  the  distal 
segment  degenerated  and  that  if  restoration  of  function  took  place,  it  was 
due  to  the  proximal  segment  sending  new  nerve  filaments  through  the  whole 
of  the  degenerated  distal  segment,  the  distal  segment  itself  being  merely  a 
guide  or  path  through  which  the  new  nerve  fibres  grew.  If  there  was  a  wide 
space  between  the  cut  ends  of  the  nerve  or  if  some  substance  was  interposed 
between  the  ends,  then  the  peripheral  segment  would  so  completely  change 
in  character  as  to  become  useless  as  a  guide.  If  this  old  doctrine  is  true,  secondary 
or  late  nerve  suture  is  useless. 

Another  and  more  hopeful  doctrine  of  repair  is  that  whUe  degeneration 
of  the  distal  segment  is  taking  place  the  cells  of  the  neurilemma  proliferate 
and  form  chains  or  bands  of  overlapping  spindle  cells  and  that  a  new  nerve 
fibre  develops  from  these.  According  to  Ballance  and  Stewart,  the  new  axis- 
cylinder  remains  immature  unless  it  unites  with  an  axis-cylinder  of  the  central 
stump.  If  this  doctrine  of  peripheral  regeneration  is  true,  secondary  nerve 
suture  may  be  expected  to  give  more  or  less  satisfactory  results  as  long  as  the 
new-formed  immature  axis-cylinders  persist  and  as  long  as  the  muscles  supplied 
remain  capable  of  function. 

It  is  believed  that  nerves  provided  with  a  neurilemma  are  capable  of  re- 
pair imder  favorable  circumstances  but  that  those  without  a  neurilemma  are 
incapable  of  repair  under  any  circumstances.  For  some  unknown  reason 
sensory  nerves  repair  much  more  readily  and  quickly  than  do  motor  ones 
{e.  g.,  recuricnce  of  facial  neuralgia  after  nerve  section  or  even  excision). 

Restoration  of  function  after  the  repair  of  a  nerve  takes  place  in  the  follow- 
ing order:  (a)  restoration  of  the  trophic  energy  of  the  tissues;  {b)  sensation; 
(c)  motion;  {d)  material  increase  of  the  substance  of  muscles  which  for  months 
have  been  inactive,  except  where  the  muscular  tissue  has  degenerated  beyond 
repair. 

The  time  which  elapses  between  nerve  suture  and  functional  repair  varies 
enormously.  Sometimes  prickling  sensations  may  be  experienced  a  few  days 
after  operation  and  motion  has  been  restored  in  from  8  weeks  to  3  1/2  years. 

Primary  Neurorrhaphy. — WTien  a  nerve  of  any  importance  is  divided, 
42  657 


658 


NERVES. 


it  ought  to  be  at  once  sutured.  The  favorite  suture  materials  are  silk  and  fine 
chromicized  catgut.  The  needles  used  should  be  as  fine  as  possible  and 
either  round  or  flat  to  avoid  needless  division  of  axis-cylinders. 

Direct  Suture. — The  stitch  includes  in  its  bite  the  sheath  as  well  as  the 
body  of  the  nerve.  Such  a  stitch  must  be  supported  by  sutures  involving  the 
sheath  alone. 

Indirect  Suture. — Fibrous  tissue  around  the  divided  nerve  is  united  by 
sutures  and  thus  holds  the  ends  of  the  nerve  in  apposition. 

It  is  well  to  combine  the  indirect  and  direct  methods.  If  there  is  loss  of 
nerve  substance  and  a  gap  exists  between  the  ends,  they  may  be  brought  to- 
gether by  stretching  their  trunks,  or  foreign  material  may  be  implanted  to  bridge 
the  gap. 

Secondary  Neurorrhaphy. — A  nerve  has  been  divided  by  injury;  recovery 
from  the  injury  is  complete,  but  the  nerve  has  never  been  united;  to  effect 

union,  the  operation  of  secondary  neurorrhaphy 
is  necessary. 

Step  I. — With,  or  preferably  without,  a  tour- 
niquet make  an  incision  along  the  course  of  the 
nerve  at  the  point  of  injury.  By  dissection  expose 
both  proximal  and  distal  portions.  The  former 
will  be  found  bulbous,  the  latter  probably  fila- 
mentous. If  the  ends  cannot  be  found  readily, 
enlarge  the  incision,  expose  the  trunk  above  and 
below,  and  follow  it  to  the  site  of  injur}'.  The 
distal  segment  may  be  so  altered  as  to  be  diffi- 
cult of  recognition;  to  identify  it  Murphy  recom- 
mends the  use  of  the  nerve  exciter.  This  is 
composed  of  a  metallic  cylinder  which  can  be  attached  at  one  end  to  a  f  aradic 
battery  while  the  other  end  is  provided  with  two  platinum  needles  or  wires, 
3  centimeters  in  length,  and  1/2  centimeter  apart.  These  tips  can  be  readily 
sterilized.     Excise  intervening  scar  tissue. 

Step  2. — ^Vivify  the  ends  of  the  nerve  by  paring  with  a  sharp  knife.  Never 
sacrifice  more  than  1/4  inch  from  either  end  in  this  procedure.  It  is  unneces- 
sary to  remove  all  the  bulb  on  the  proximal  stump  (Bowlby,  Jacobson).  Unite 
the  ends  by  suture,  if  necessary,  stretching  the  proximal  portion  of  the  trunk 
to   obtain   apposition. 

An  extraordinary  case  of  secondary  nerve  suture  of  the  facial  nerve  is  re- 
ported by  Emmet  Rixford.  Eight  weeks  after  an  injury  the  facial  nerve 
was  identified  as  it  left  the  stylomastoid  foramen  and  was  found  to  be  divided 
I  cm.  below  this  point.  The  distal  segment  was  found  with  great  difficulty 
by  first  exposing  the  two  principal  branches  in  the  parotid  and  tracing  them 
back.  The  gap  between  the  segments  was  about  i  cm.  The  proximal  seg- 
ment after  vivification  was  so  short  that  stitches  could  not  be  introduced. 
Rixford  cut  away  enough  of  the  mastoid  process  and  the  external  wall  of  the 


Fig.   754. 


NERVE   SUTURE. 


659 


aqueduct  of  Fallopius  so  that  the  nerve  could  be  mobilized  and  the  two  seg- 
ments united  by  sutures.  The  result  was  entirely  good.  In  repose  the  two 
sides  of  the  face  looked  alike  and  the  patient  could  close  the  eye  on  the 
affected  side  independently  of  the  other  \\-ith  an  expressive  wink.  ("Trans. 
Am.  Surg.  Assoc,"  xxii.) 


Fig.  755. 

The  methods  of  applying  sutures  (silk,  hemp,  catgut,  preferably  inserted 
by  means  of  intestinal  needles)  are  sufficiently  shown  in  Figs.  754,  755. 

When  direct  apposition  of  the  divided  ends  of  the  nerve  is  impossible 
various  means  of  bridging  the  gap  have  been  devised;  some  of  the  best  of  these 
are  sho^Ti  in  Figs.  756,  757,  758. 

When  a  divided  nerve  has  been  united  by  cicatrical  but  not  by  nerve  tissue, 
repair  may  be  obtained  by  Bruns'  method  (Fig.   759). 

Implantation  of  nerve  from  the  human  body  or  of  the 
sciatic  nerve  or  spinal  cord  of  other  animals  {e.  g.,  rabbits) 
has  been  employed.  Gliick  recommends  placing  these  grafts 
inside  decalcified  bone  tubes  and  tucking  the  vivified  stumps 
of  the  nerve  to  be  united  into  the  open  ends  of  the  tube,  there 
fixing  them  with  sutures. 

Formalinized  portions  of  arteries  may  be  used  in  place  of 
the  bone  tubes.     (Foramitti.) 

Powers  ("Trans.  Am.  Surg.  Assoc,"  xxii)  comes  to  the 
following  conclusions:  "Although  correction  of  the  evils  re- 
sulting from  a  gap  in  the  continuity  of  a  nerve  is  a  matter 
of  great  importance  in  a  given  case,  it  hardly  seems  possible 
at  this  time  to  say  definitely  what  form  of  bridging  should  be  Fig.  756. 
employed.  More  cases,  and  especially  cases  recorded  later 
and  better,  are  needed.  Neoplasty  and  implantation  (anastomosis)  are  always 
available  resources,  and  for  the  present  it  would  seem  that  they  should  be 
preferred.  Resection  of  bone  may  be  ad\asable  in  selected  cases.  Trans- 
plantation of  foreign  grafts  should  be  abandoned.  It  is  hardly  necessary  to 
say  that  prognosis  in  an  individual  case  should  always  be  guarded  and  that 
repeated  operations  may  be  necessary." 


66o 


NERVES. 


Verga  ("La  Clinica  Chir.,"  xviii,  No.  i,  Ref.  "  Journ.  de  Chir.,"  April,  1910) 
as  a  result  of  a  series  of  experiments  came  to  the  following  conclusions: 

1.  Sutures  of  the  ends  of  the  nerve  brought  into  apposition  by  stretching 
(Schiiller's  method)  permit  the  repair  of  losses  of  substance  of  about  2  to  3  cm. 

2.  "Distance  sutures"  give  equally  good  results  whether  catgut  or  silk  is 
used. 


A  \ 

\^ 

c 

~"a' 

■      ^\ 

k 

^¥.-^ 

c 

^~~^            ^ 

^^ 

I^IG.   757.— Two  parallel  nerves  divided  at  different  levels,  with  loss  of  substance  from  each. 
Unite  A  to  vivified  point  A'.     Unite  D  to  B.     Unite  C  to  vivified  point  C 

3.  Tubular  suture.  Fresh  arteries  give  good  results;  rubber  tubes  medi- 
ocre while  Payr's  metallic  tubes  (magnesium)  seem  better  as  protectors  after 
neurorrhaphy  than  as  tubular  sutures. 

4.  Homo-  or  heteroplastic  transplants  give  apparent  union  but  the  implant 
surely  degenerates  and  only  acts  as  a  guide  into  which  new  nerve  fibres  pene- 
trate from  the  central  segment. 


Fig.   758. — Nerves  divided — -loss  of  substance.     Unite  end  A  to  vivified  point  C  on  neighbor- 
ing and  parallel  nerve.     Ignore  segment  B. 

5.  Autoplasty  by  flaps  (autoplastic  elongation)  ought  to  be  abandoned- 
It  aggravates  instead  of  ameliorating  the  lesion. 

6.  Termino-lateral  anastomosis  provides  an  anatomical  reunion  and 
histologically  it  can  be  demonstrated  that  fibres  pass  directly  from  the  nerve 
implanted  into  the  nerve  to  be  regenerated.     Neurotization  of  the  paralyzed 


NEURORRHAPHY. 


66l 


trunk  may  be  obtained  however  the  operation  is  performed  and  even  if  the 
stump  is  not  vivified.  The  healthy  nerve  suffers  more  or  less  from  the  operation 
but  its  lesions  recover  by  the  same  processes  as  the  paralyzed  nerve. 

7.  After  neurectomy  the  actual  cautery  applied  to  the  nerve  stump  does  not 
prevent  regeneration. 

Treudein  ("Miinch.  med.  Woch.,"  June  19,  1906)  reports  that  remarkably 
good  results  were  obtained  by  the  Japanese  during  the  Russo-Japanese  war 
by  covering  the  line  of  suture  or  of  bridging  of  nerves  by  formalinized  arteries 
which  had  been  preserved  in  alcohol. 

In  a  case  of  fracture  of  the  humerus  in  which  4  cm.  (one  and  a  half  inches) 
of  the  musculo-spiral  nerve  had  been  destroyed  Ramsauer  excised  a  10  cm. 
(four  inch)  segment  of  the  basilic  vein,  threaded  four  silk  sutures  through 
the  excised  vein,  used  these  threads  thus  covered  or  insulated  to  bridge  the  gap 
in  the  nerve.     Fairly  good  function  was  reestablished  in  six  months. 


Fig.  759. 


Lotheisen  uses  gelatin  tubes  hardened  in  formalin  and  preserved  in  alcohol. 
Murphy,  when  possible,  protects  the  line  of  union  with  fascia,  muscle  or  fat. 
When  this  is  impossible,  e.  g.,  at  the  ankle  or  wrist,  he  envelops  the  line  of 
union  with  Cargile  membrane  or  with  a  sheet  of  paste  made  from  equal  parts 
of  oil  of  sesame  and  paraffin  \vith  a  melting  point  of  107°  F. 

The  favorite  method  of  bridging  the  gap  is  by  means  of  several  strands  of 
chromicized  catgut  (distance  sutures).  In  order  to  unite  severed  nerves, 
several  surgeons  have  successfully  excised  segments  of  the  humerus  or  of  the 
forearm  bones,  thus  shortening  the  limb  and  attaining  their  aim. 

After  neurorrhaphy  or  nerve  transplantation  complete  rest  of  the  parts, 
without  tension  on  the  line  of  suture,  must  be  maintained  until  union  is  complete. 
The  subsequent  treatment  consists  in  massage,  electrical  stimulation,  and 
proper  gymnastics.  Excellent  function  is  sometimes  obtained  long  after  all 
hope  of  such  has  been  abandoned.  Sensation  may  be  expected  to  return  be- 
fore motion,  generally  after  the  lapse  of  two  to  four  weeks.     Motion  is  rarely 


662  NERVES. 

obtained  until  months  after  operation.  In  76  cases  of  neurorrhaphy  (Till- 
manns)  67  per  cent,  were  successful.  Of  these  76  cases,  33  were  secondary 
operations  with  24  decided  successes. 

As  in  the  case  of  tendon,  so  with  nerves,  various  methods  of  transplantation 
may  be  used.  Dumstrey  ("  Centralblatt  f.  Chir.,"  1902,  p.  376)  describes 
a  case  where  the  ulnar  nerve  was  extensively  destroyed  more  than  two  years 
previously  by  a  fracture  of  the  elbow.  He  implanted  the  peripheral  portion 
of  the  nerve  into  a  button-hole  in  the  median  nerve,  and  inserted  "distance 
sutures"  of  catgut  between  the  proximal  portion  of  the  ulnar  and  the  same 
point  in  the  median.  Within  three  months  there  were  a  notable  return  of  sen- 
sation, beginning  of  motion,  and  a  loss  of  previously  existing  contracture. 

A  case  of  extensive  destruction  of  the  radial  nerve  is  reported  by  C.  Sick 
and  A.  Saenger  ("Archiv  f.  klin.  Chir.,"  liv,  271),  who  operated  as  follows: 
(i)  Exposure  peripheral  portion  radial  nerve  in  forearm.  (2)  Exposure  median 
nerve  in  forearm  through  the  same  incision.  (3)  Splitting  of  a  flap,  with 
base  upwards  from  the  median  nerve.  (4)  Conduction  of  this  flap  under  the 
muscles  and  suture  of  it  to  the  exposed  portion  of  the  radial  nerve.  After 
several  months  there  was  no  improvement,  but  when  i  1/2  years  had  elapsed 
the  paralysis  had  almost  entirely  disappeared. 

Suture  of  Recurrent  Laryngeal  Nerve. — Shelton  Horsley  ("Annals  of  Surg.," 
li,  524)  reports  a  case  in  which  the  left  recurrent  laryngeal  nerve  was  divided  by 
a  bullet  at  a  point  just  before  the  nerve  entered  the  larynx.  The  voice  was  hoarse 
and  weak.  Respiration  was  impeded.  The  left  vocal  cord  was  paralyzed  and 
the  larynx  above  the  glottis  was  congested.  Horsley  operated  as  follows: 
Make  an  incision  along  the  anterior  border  of  the  left  sterno-mastoid.  The 
middle  of  this  cut  is  opposite  the  inferior  limit  of  the  larynx.  Retract 
the  sterno-mastoid  and  with  it  the  carotid  and  internal  jugular  outwards 
Expose  the  left  lobe  of  the  thyroid  and  retract  it  to  the  right  along  with  the  tra- 
chea and  larynx.  Look  for  the  nerve  in  the  groove  between  the  trachea  and 
oesophagus.  In  Horsley's  case  the  wounded  part  of  the  nerve  was  surrounded 
by  a  mass  of  scar  tissue.  About  8  mm.  of  involved  nerve  was  excised  and  the 
divided  ends  united  by  a  fine  catgut  suture.  Six  days  after  operation  there 
was  no  improvement  in  the  symptoms.  Three  months  later  the  movements 
of  the  glottis  were  almost  normal  though  the  left  vocal  cord  seemed  a  little 
weak.  The  voice  was  no  longer  hoarse  but  had  not  regained  its  full  volume. 
Shepherd  has  successfully  sutured  the  recurrent  laryngeal  nerve  after  it  had 
been  accidentally  divided  during  a  strumectomy. 

Kenneth  MacKenzie's  work  on  resection  of  the  sciatic  nerve  is  of  very  great 
importance  even  although  it  consists  of  the  report  of  a  single  case  ("Annals  of 
Surg.,"  July  19,  1909). 

Because  of  agonizing  pain,  etc.,  resulting  from  a  tumor  of  the  sciatic  nerve 
ten  and  three-quarter  (10  3/4)  inches  of  the  nerve  was  removed  (x-y,  Fig.  760). 
The  wound  was  closed  and  healing  took  place.  Twenty-one  days  after  the 
first  operation  an  incision  was  made  along  the  line  of  the  original  cut  in  the 


NEURORRHAPHY. 


663 


thigh  but  extending  down  to  a  point  immediately  behind  the  internal  malleolus. 
Through  this  long  incision  the  stump  of  the  sciatic  nerve  was  exposed,  the  ends 
of  the  popliteal  nerves  were  found  (and  the  external  anastomosed  laterally  to 
the  internal),  the  internal  popliteal  nerve  was  exposed  down  to  the  ankle  and 


Fig.  760. 

from  it  a  flap  16  3/4  inches  long  and  about  i  1/2  line  in  diameter  and  reflected 
upwards,  care  being  taken  to  avoid  the  division  of  any  collateral  branches. 
The  end  of  the  long  flap  was  implanted  into  a  split  made  in  the  stump  of  the 
sciatic  nerve.     The  flap  "was  carefully  placed  over  the  underlying  muscles 


664  NERVES. 

and  imbedded  in  them  throughout  its  length  by  a  slender  iodized   suture." 
Healing  was  per  primam  and  there  was  much  improvement. 

Sixty-seven  days  after  the  first  operation  exposure  of  the  nerve  tract  showed 
a  definite  path  of  nerve  tissue  in  the  sciatic  gap.  The  external  popliteal  nerve 
was  now  exposed  and  a  flap  split  from  it  was  placed  alongside  the  original 
graft,  but  tucked  in  a  separate  muscular  bed.  Healing  per  primam.  (Fig.  760 
explains  the  steps  of  the  operation.) 

Immediately  after  the  primary  operation  not  only  was  all  sensory  and 
motor  transmission  eliminated  throughout  the  sciatic  area  but  in  addition 
all  means  of  conveyance  of  stimuli  by  afferent  nerves  of  whatsoever  kind. 
There  were  marked  trophic  disturbances.  The  result  of  the  reparative  opera- 
tion was: 

"i.  Trophic  recovery  is  practically  complete.  There  is  now  no  tendency 
to  the  formation  of  blebs  and  ulcers  and  the  skin  has  recovered  its  natural 
texture  and  color. 

"2.  There  has  been  extensive  development  of  protopathic  sensibility,  much 
more  than  could  possibly  be  explained  by  overlapping  from  the  district  of  the 
anterior  crural  nerve. 

"3.  There  has  been  much  recovery  of  epicritic  sensibility,  as  shown  by  com- 
parison of  the  areas  of  sensory  distribution  in  both  legs  by  diagram. 

"4.  There  is  also  universal  recovery  of  deep  sensation,  which  is  said  to  be 
lost  when  all  motor  and  all  sensory  nerves  to  a  given  part  are  divided. 

"5 .  Recovery  has  taken  place  of  motion  and  power  in  large  groups  of  muscles, 
which  immediately  after  the  excision  of  the  nerve  were  reduced  to  a  paralytic 
state,  displaying  the  usual,  signs  of  paralysis  and  the  reaction  of  degeneration. 

"6.  The  sign  afforded  by  the  foot.  In  the  earlier  stages  of  locomotion  the 
foot  was  helpless  and  dragged;  at  the  present  time  it  shows  muscular  control 
and  easy  locomotion. 

"7.  The  relatively  small  area  of  thermic  anaesthesia,  which  is  practically- 
coterminous  with  the  area  of  absolute  analgesia. 

"8.  The  direct  sensibility  of  the  new  nerve-tract  to  deep  pressure  and  the 
transmission  of  painful  sensibility  thereby  to  the  foot. 
"9.  The  possession  of  muscular  sense  unimpaired. 

"10.  Independent  and  unaided  locomotion." 

NERVE  ANASTOMOSIS. 

I.  Nerve  Anastomosis  for  Facial  Paralysis. — The  first  operation  of  this 
kind  was  performed  by  Ballance  and  Purves  in  1895.  Faure  operated  in  1898, 
and  in  1900  Robert  Kennedy  in  a  case  of  severe  facial  spasm  divided  the  facial 
nerve,  uniting  the  proximal  extremity  of  its  distal  portion  to  the  partially 
divided  spinal  accessory  nerve.     The  result  was  perfect. 

Harvey  Gushing  ("Annals  of  Surgery,"  May,  1903)  reports  a  case  in  which 
the  facial  nerve  was  destroyed  near  the  stylo-mastoid  foramen.     After  the 


FACIAL    PALSY. 


665 


orginal  wound  (pistol  wound)  was  thoroughly  healed,  the  following  operation 
was  performed: 

I.  Incision  along  anterior  border  sterno-mastoid. 


Fig.   761. — (Cushing,  "Annals  of  Surg.") 

2.  Exposure  spinal  accessory  nerve  at  point  of  entry  into  deep  surface  of 
sterno-mastoid,  about  two  inches  below  the  tip  of  the  mastoid. 

Exposure  disatal  segment  of  facial  nerve  by  incising  the  posterior  border  of 


666  NERVES. 

the  parotid  gland  in  a  line  parallel  to  and  direcdy  under  the  original  skin-in- 
cision. If  this  cut  be  made  carefully,  one  of  the  main  branches  of  flie  nerve 
is  certain  to  be  encountered  and  can  be  followed  back  by  blunt  dissection 
without  (Fig.  761)  isolating  the  nerve  itself. 

3.  Square  division  of  facial  nerve  close  to  the  scar  tissue  existing  at  point 
of  original  injury. 

4.  Division  spinal  accessory  nerve  at  point  of  entry  into  the  muscle. 

5.  Approximation  of  the  two  nerves,  without  tension,  over  the  posterior 
belly  of  the  digastric  muscle.     Suture. 

6.  Closure  of  wound. 

Improvement  was  noted  after  an  extraordinarily  short  time.  The  ultimate 
result  was  most  gratifying. 

Murphy  insists  on  the  importance  of  imbedding  the  point  of  nerve  union 
inside  a  muscle  belly  {e.  g.,  stemo-hyoid) .  In  one  case  he  saw  the  point  of 
union  imbedded  and  compressed  into  uselessness  by  scar  tissue.  After  freeing 
the  nerve  from  scar  tissue  and  imbedding  it  in  muscle  a  good  result  was  obtained. 

Instead  of  using  the  spinal  accessory,  the  hypoglossal  nerve  has  been  utilized 
to  supply  nerve  stimuli  to  the  facial.  This  was  first  done  by  Ballance  and 
Stewart,  later  by  Frazier.  The  glossopharyngeal  nerve  has  also  been  similarly 
used.     The  various  operations  for  facial  palsy  may  be  systematized  as  follows: 

Anatomy. — The  facial  nerve  emerges  through  the  stylo-mastoid  foramen 
where  it  is  deeply  seated;  from  here  it  runs  "downwards,  outwards  and 
a  little  forwards  to  turn  or  wind  round  the  styloid  process,  after  this  its  course 
is  almost  horizontally  forwards  until  it  crosses  the  posterior  auricular 
artery  and  immediately  plunges  into  the  parotid  gland.  The  horizontal  portion 
of  the  nerve  is  situated  at  the  level  of  the  tip  of  the  lobule  of  the  ear,  i.  e.,  about 
3/4  inch  below  the  lower  border  of  the  zygomatic  arch." 

The  Spinal  Accessory  Nerve. — The  external,  spinal  or  surgical  portion  of 
this  nerve  emerges  from  the  skull  through  the  jugular  foramen;  from  here  it 
passes  downwards,  outwards  and  a  little  backwards  in  front  of  (rarely  behind) 
the  internal  jugular  vein  between  that  vein  and  the  occipital  artery  which 
crosses  it  perpendicularly.  The  nerve  now  lies  exactly  between  the  transverse 
process  of  the  atlas  and  the  posterior  border  of  the  digastric.  Below  this  point 
the  nerve  passes  behind  the  posterior  border  of  the  parotid  to  enter  the  deep 
surface  of  the  sterno-mastoid  2  inches  below  the  apex  of  the  mastoid  process. 

The  Hypoglossal  Nerve. — The  hypoglossal  nerve  leaves  the  skull  through 
the  anterior  condylar  foramen  and  lies  on  the  inner  side  of  the  deep  cervical 
vessels.  As  it  descends,  the  nerve  comes  forward  between  the  internal  carotid 
artery  and  jugular  veins  to  the  lower  border  of  the  digastric  muscle  where  it 
curves  forward  round  the  origin  of  the  occipital  artery,  the  sterno-mastoid 
branch  of  which  turns  downwards  over  the  nerve.  From  this  point  the  nerve 
runs  forwards  above  the  hyoid  bone,  passes  under  the  tendon  of  the  digastric, 
the  lower  end  of  the  stylo-hyoid  and  the  mylo-hyoid  muscles,  and  crosses  the 
external  carotid  and  lingual  arteries. 


NERVE  ANASTOMOSIS.  667 

Spino-facial  Anastomosis. — Step  1. — Incision  along  the  anterior  border  of 
the  sterno-mastoid  beginning  above  in  the  groove  between  the  external  ear  and 
the  mastoid  at  the  level  of  the  tragus  and  ending  at  a  point  about  5  inches  lower. 

Step  2. — Retract  the  ear  forwards.  Divide  the  fibrous  tissues  covering  the 
mastoid  so  as  to  gain  access  to  its  anterior  border.  Expose  the  anterior  border 
of  the  sterno-mastoid. 

Step  3. — With  blunt  dissection  penetrate  between  the  parotid,  the  anterior 
border  of  the  mastoid.  Move  the  dissecting  instrument  horizontally  and  not 
vertically,  to  avoid  injuring  the  nerve.  The  nerve  should  be  found  at  a  depth 
of  a  little  less  than  1/2  inch  from  the  surface  of  the  mastoid  at  the  junction  of 
its  lower  and  middle  thirds  (Marion).  Isolate  the  nerve  and  divide  it  as  far 
back  as  possible. 

Step  3. — Open  the  sheath  of  the  sterno-mastoid  longitudinally.  Demonstrate 
the  transverse  process  of  the  atlas  about  1/2  inch  below  the  mastoid,  and  expose 
it  clearly  to  sight  by  bluntly  dividing  the  fibrous  tissues  covering  it.  Demon- 
strate the  posterior  belly  of  the  digastric  in  front  of  the  atlas.  The  spinal 
accessory  nerve  lies  between  the  transverse  process  of  the  atlas  behind  and  the 
digastric  in  front.     Isolate  the  nerve. 

Step  4. — Divide  the  nerve  at  its  entrance  into  the  sterno-mastoid,  and  make 
an  end-to-end  anastomosis  between  its  proximal  segment  and  the  distal  seg- 
ment of  the  facial.  Instead  of  completely  dividing  the  spinal  accessory  nerve, 
a  hole  may  be  cut  in  its  side  and  into  this  the  facial  nerve  implanted  (end-to-side 
anastomosis).     The  end-to-end  anastomosis  seems  preferable. 

Step  5. — Bury  the  line  of  nerve  suture  in  the  belly  of  the  digastric  muscle 
after  incising  the  muscle  for  this  purpose. 

Step  6. — Close  the  wound  with  buried  and  superficial  sutures. 

Hypoglosso-facial  Anastomosis. — Step  i. — ^From  a  point  on  the  level  of  the 
tragus,  in  the  groove  between  the  external  ear  and  the  mastoid,  make  an  incision 
downwards  along  the  anterior  border  of  the  sterno-mastoid  to  a  point  a  trifle 
below  the  angle  of  the  jaw;  from  this  low  point  cut  forwards  horizontally  on  the 
level  of  the  hyoid  bone,  for  about  i  inch. 

Step  2. — Expose  and  divide  the  facial  nerve  as  in  the  spino-facial  anasto- 
mosis. 

Step  3. — In  the  lower  part  of  the  wound  open  the  sheath  of  the  sterno- 
mastoid  anteriorly,  retract  the  muscle  backwards,  divide  the  deep  layer  of  the 
sheath  of  the  mastoid  at  the  level  of  the  greater  horn  of  the  hyoid.  The  nerve 
is  to  be  sought  either  posteriorly  where  it  crosses  the  external  carotid  (Fig.  762,) 
or  anteriorly  between  the  greater  horn  of  the  hyoid  and  the  posterior  belly  of 
the  digastric. 

Step  4. — Free  the  nerve  very  gently  from  its  surroundings.  Divide  the  nerve 
so  far  forwards  that  enough  isolated  nerve  trunk  is  left  to  be  turned  upwards  and 
forwards  and  united  without  tension  to  the  distal  segment  of  the  divided 
facial  nerve.     Complete  the  anastomosis. 

Steps  5  and  6. — As  in  spino-facial  anastomosis. 


668 


NERVES. 


Indications  for  Operation  for  Facial  Palsy. — i.  Where  it  is  known 
that  the  facial  nerve  is  completely  divided,  immediately  unite  its  divided  ends 
if  possible;  if  this  is  impossible  perform  spino-facial  or  hypoglosso-facial  anas- 
tomosis as  soon  as  possible. 

2.  When  there  is  reasonable  doubt  as  to  the  permanency  and  completeness 
of  the  lesion,  delay  is  justifiable.  If  there  is  no  sign  of  recovery  in  six  months, 
operate  (Frazier). 

3.  In  old  cases  test  the  facial  muscles,  if  they  are  completely  atrophied  and 
no  longer  respond  to  the  faradic  current,  probably  operation  will  do  no  good. 
If  the  muscles  respond  to  faradic  stimulation  operation  is  proper. 


Hyno- 
glossal  n. 


Fig.  762. — {Marion.) 


4.  Facial  palsy  from  "cold."  This  is  probably  an  infective  neuritis  (Spiller). 
The  prognosis  is  usually  good  without  operation.  If,  after  four  to  six  months, 
the  facial  muscles  are  still  almost  completely  paralyzed  and  reaction  of  degener- 
ation is  pronounced,  Spiller  would  recommend  anastomosis.  The  same  rules 
apply  to  facial  paralysis  from  middle  ear  disease. 

Choice  of  Operation. — i.  In  palsy  from  division  of  the  facial  nerve  im- 
mediate reunion  is  always  desirable  but  not  often  possible. 

2.  Spino-facial  anastomosis  is  somewhat  more  easily  performed  than  is  the 
hypoglosso-facial  operation,  and  the  muscles  paralyzed  by  the  nerve  section 
are  less  important.  The  spinal-accessory  nerve,  however,  is  dominated  by  the 
centres  for  associated  movements  of  the  shoulder,  hence  after  operation  there 
are  liable  to  be  movements  of  the  facial  muscles  every  time  the  patient  raises 


BRACHIAL   PALSY.  669 

his  shoulder.  Mr.  Ballance  has  given  up  spino-facial  anastomosis  on  account 
of  the  difficulty  of  securing  dissociation. 

3.  Hypoglosso-facial  anastomosis  is  not  much  more  difficult  than  spino- 
facial,  the  muscles  supplied  are  not  of  prime  importance.  The  hypoglossal 
cortical  centre  is  functionally  more  allied  to  the  facial  centre  than  is  that  of  the 
spinal  accessary. 

Spiller  writes:  "In  employing  hypoglossal  as  the  nerve  for  anastomosis  with 
the  facial  it  is  possible  that  emotional  movements  may  be  restored,  and  such 
seems  to  have  been  the  result  in  a  case  observed  by  Koster  and  Bernhardt,  in 
which  the  corner  of  the  mouth  on  the  afifected  side  was  moved  during  laughter." 

Treatment  of  Facial  Paralysis  by  Muscle  Transplantation. — A.  Jianu 
("  Deutsche  Zeitsch.  fiir  Chir.,"  cii,  p.  577.  Ref.  "Journal  de  Chir.,"  Feb.,  1910) 
has  operated  by  taking  a  flap  from  the  sterno-mastoid  muscle  (pedicle  above)  and 
suturing  it  to  the  angle  of  the  mouth.  The  result  was  satisfactor>^  Jonnesco, 
following  Jianu's  principle,  exposed  the  masseter  by  a  curved  incision  following 
the  edge  of  the  inferior  maxilla  (both  the  ascending  and  horizontal  rami) ;  split  the 
masseter  in  the  direction  of  its  fibres;  separated  the  anterior  portion  of  the  muscle 
from  its  insertion  into  the  jaw,  and  so  formed  a  muscular  flap  attached  to  the 
zygoma.  This  flap  he  sutured  to  the  angle  of  the  mouth.  The  result  was 
correction  of  the  deviation  of  the  mouth;  prevention  of  the  escape  of  saliva; 
ability  voluntarily  to  move  the  angle  of  the  mouth. 

The  operation  does  not  pretend  to  remedy  the  paralysis  of  the  orbicularis 
muscle  and  must  be  of  very  limited  value.  Cuneo  remarks  that  Jianu's  operation 
should  be  reserved,  in  cases  of  total  facial  paralysis,  to  those  in  which  nerve 
anastomosis  has  failed  and  that  when  performed  it  should  be  supplemented 
by  some  operation  on  the  eyelids  such  as  angular  tarsorrhaphy. 

II.  DUCHENNE-ERB  PARALYSIS. 

Paralysis  of  certain  groups  of  muscles  and  anaesthesia  of  various  regions  may 
result  from  injuries  to  the  brachial  plexus.  These  injuries  may  be  due  to 
tearing,  stretching,  or  compression  of  the  plexus  during  birth  (Duchenne)  or  to 
trauma  received  latter  in  life.  The  part  of  the  plexus  affected  is  at  that  point 
where  the  anterior  primary  divisions  of  the  fifth  and  sixth  cervical  nerve  unite. 
The  motor  fibres  in  these  two  nerve  roots  supply  the  deltoid;  supraspinatus  and 
infraspinatus;  biceps;  brachialis  anticus;  supinator  longus  and  brevis,  and  the 
teres  minor.  Thus  in  a  typical  case  of  Duchenne- Erb  paralysis  the  arm  can- 
not be  adducted  at  the  shoulder,  flexion  of  the  elbow  is  impossible,  the  forearm 
is  in  a  position  of  pronation,  the  whole  arm  is  rotated  outwards  to  such  an 
extent  that  the  palm  of  the  hand  may  be  directed  outwards. 

Wilfred  Harris  and  V.  W.  Low  ("Brit.  Med.  Jour.,"  Oct.  24,  1903)  believe 
that  Markoe's  case  ("Annals  of  Surg.,"  1885,  ii,  185)  of  division  of  the  fifth 
cervical  root  proves  that  the  deltoid,  spinati,  biceps,  and  brachialis  anticus 
derive  their  whole  motor  supply  from  this  source,  whi  e  the  supinator  longus  is, 
at  least  in  part,  indebted  to  it  for  its  motor  impulses. 


670 


NERVES. 


When  a  case  presenting  the  symptoms  enumerated  shows  no  improvement 
after  two  or  more  months  of  treatment  by  electricity,  massage,  etc.,  but,  on 
the  contrary,  the  electrical  reactions  of  degeneration  begin  to  appear,  then 
operative  treatment  becomes  proper.  There  are  two  methods  by  which 
improvement  may  be  attained — one  by  nerve  anastomosis,  the  other  by  muscle 
transplantation  or  transference. 

(A)  Direct  Method. — Robert  Kennedy's  Operation. — ("Brit.  Med.  Jour.," 
Feb.  7,  1903.)  Place  the  patient  on  his  back,  with  a  pan  under  the  shoulders  to 
permit  of  the  head  being  well  thrown  back.  Incline  the  head  and  face  to  the 
opposite  side. 

SUBCLAt//VS. 

SUPRASCAPULAR. 


/Supra-spinatus.  \ 
( /)ifra  -  spi?t  at  us. I 


POST.THORACIC. 

ISeiratils   me/ff/tits) 

A  NT.  THORACIC-:' 
SUBSCAPULAR:-- 

/Suiscapularis .  j 
Uatisslmus  dors/. J 
\  Teres  major.      ' 


mSCULO-CUTANEOUS. 

^^^      /Coraco-Brac?tiulis\ 
^  \Biceps,Braxh.Ant.l 

,M£DIAN. 

'cmcomiEX. 

•'  /  Deltoid.    \ 
l/cre'S  -  minor.j 

'MUSCULO-SPmL. 

((Supinator  Io)/.giJs\ 
e.t  ire  vis.  \ 

Brack  Jn,i.iTriceps\ 
AnconeJ. 
_    btcisors  of  Haud.] 


Fig.  763. 

Step  I. — ^From  the  junction  of  the  middle  and  lower  thirds  of  the  outer 
margin  of  the  sterno-mastoid  make  an  incision  outwards  and  downwards  to 
the  junction  of  the  outer  and  middle  thirds  of  the  clavicle.  Divide  the  deep 
fascia  between  the  sterno-mastoid  and  trapezius.  Expose  the  omo-hyoid  below 
the  lower  edge  of  the  wound.  Above  the  omo-hyoid  expose  the  scalenus  anti- 
cus  muscle  and  demonstrate  the  nerve-trunks  emerging  from  under  it.  Trace 
the  two  upper  nerve-trunks  outwards  to  their  junction. 

Step  2. — Having  found  the  junction  of  the  fifth  and  sixth  nerves,  recog- 
nize the  various  branches  and  free  them  from  adhesions  (Fig.  763).  Free 
the  main  trunks  from  the  adhesions  which  seem  to  be  always  present. 

The  accompanying  illustrations  (Figs.  764,  765)  taken  from  A.  S.  Taylor's 
article  on  "Brachial  Birth  Palsy"  ("Journ,  A.  M.  A,"  Jan.  12,  1907)  illustrate 
well  the  anatomy  of  the  brachial  plexus. 

Step  3. — Note  the  condition  of  the  isolated  nerve.     Kennedy  has  always 
found  it  to  be  in  a  hopelessly  cicatricial  condition.     If  the  whole  nerve  seems 
to  be  composed  of  scar  tissue,  divide  the  fifth  and  sixth  above  the  diseased 
area.     The  cut  surface  ought  to  show  a  healthy  appearance;  if  not,  slice  off 


BRACHIAL   PALSY.  67 1 

more  of  the  nerve  until  healthy  tissue  is  reached.  Pull  the  diseased  area  in- 
wards and  put  on  the  stretch  the  three  peripheral  divisions  of  the  nerve,  viz.,  the 
supra-scapular  nerve,  the  branch  to  the  outer  and  that  to  the  posterior  cord  of 
the  plexus.  Divide  these  three  branches  at  points  beyond  the  disease,  the 
section  being  made  through  healthy  nerve. 

Step  4. — Suture  the  three  peripheral  stumps  to  the  two  proximal  stumps 
of  nerve  by  means  of  fine  chromicized  catgut  threads.  Before  approximating 
the   divided  nerve  ends  and  tying  the  sutures,  push  the  shoulder  upwards  and 


Fig.  764. — -{Taylor.) 
A.  Scalenus   anticus.     B.  Phrenic   n.     C.  Int.    jugular.     D.  transversalis   colli   a.     E. 
Seventh   root.     F.  Omo-hyoid.     G.  Fifth   root.     H.  Scalenus   medius.     I.  Sixth   root.     K. 
Suprascapular  n.     L.  Ext.  ant.  thoracic  n.     M.  Clavicle.     N.  Nerve  to  subclavius. 

incline  the  head  to  the  side  being  operated  upon.  This  relieves  tension  and 
permits  of  approximation.  Cover  the  line  of  nerve  suture  with  muscle,  fascia 
or  some  material  like  Cargile's  membrane. 

Step  5. — Close  the  external  wound.  Apply  dressings.  With  plaster-of- 
Paris  or  a  suitable  apparatus  keep  the  shoulder  elevated  and  the  head  inclined 
to  the  side  on  which  operation  has  been  performed,  and,  above  all,  prevent 
motion  of  the  head  on  the  shoulders.  When  the  lesion  is  more  extensive, 
especially  when  it  lies  beneath  the  clavicle,  continue  the  skin  incision  down- 
wards between  the  pectoralis  major  and  deltoid.  Separate  these  muscles. 
Divide  the  clavicle  in  the  same  line,  also  the  sub-clavius  and  omo-hyoid  mus- 
cles and  supra-scapular  vessels.  Pull  the  outer  fragment  of  the  clavicle  and 
the  shoulder  outwards  exposing  the  entire  plexus  to  the  upper  margin  of  the 


672 


NERVES. 


pectoralis  minor,  which  may  also  be  divided  if  necessary.     When  the  nerve 
suture  is  completed  reunite  the  divided  muscles  and  bone. 

After  tw^o  w^eeks  the  fixed  dressings  may  be  discarded.  Kennedy  does 
not  advise  any  special  after-treatment,  believing  that  the  nervous  impulses, 
which  can  now  reach  the  muscles,  will  lead  to  their  satisfactory  development. 
Most  surgeons  will  undoubtedly  endeavor  to  assist  recovery  by  the  use  of 
electrical  stimulation  and  massage. 


Fig.  t 6$.— {Taylor.) 
A.  Phrenic  11.  B.  Scalanus  ant.  C.  Int.  jugular.  D.  O.  transversalis  colli  a.  E. 
Omo-hyoid.  F.  R.  Suprascapular  a.  G.  VIII.  cervical  and  dorsal  root.  H.  Muscular 
branch.  I.  Subclavian  v.  J.  Fifth  root.  K.  Sixth  root.  L.  Scalenus  medius.  M.  Nerve 
to  subclavius.  N.  Suprascapular  n.  S.  Clavicle  and  subclavius.  T.  Pect.  major.  U. 
Ant.  thoracic  n. 


Harris  and  Low  think  that  Kennedy  relies  too  much  on  the  physical  appear- 
ance of  the  nerves  when  exposed,  and  as  a  consequence  may  be  led  to  excise  too 
much.  Thus,  if  the  deltoid,  spinati,  biceps,  and  brachialis  anticus  muscles 
(and  perhaps  also  the  supinator  longus)  are  paralyzed,  and  if  Markoe's  obser- 
vation be  remembered,  then  after  exposing  the  nerves  it  would  be  wise  sepa- 
rately to  stimulate  faradically  the  fifth  and  sixth  nerves.  If  stimulation  of 
the  fifth  fails  to  gain  response  while  stimulation  of  the  sixth  does,  then  these 


BRACHL\L    PALSY.  673 

observers  advise  that  the  lifth  nerve  be  followed  upwards,  be  divided  well 
above  the  junction,  and  the  proximal  end  of  its  peripheral  portion  be  anasto- 
mosed to  a  split  in  the  side  of  the  sixth  nerve.  Part  of  this  advice  does  not 
appeal  to  the  author,  as  there  seems  to  be  little  advantage  to  be  gained  by 
it,  in  that  the  portion  of  the  fifth  nerve  grafted  on  to  the  sixth  has  been  proved 
to  be  incapable  of  conduction. 

Undoubtedly  Harris  and  Low  are  right  in  advising  the  use  of  electrical 
tests  before  excising  portions  of  the  nerve,  as  by  this  means  nerve  tissue  may 
be  saved  which  would  otherwise  be  destroyed.  The  benefit  of  analytical 
observation  during  operation  is  shown  by  a  case  in  which  Harris  and  Low 
made  use  of  cross-union.     The  case  was  one  of  atypical  Duchenne-Erb  palsy: 

A  girl,  aged  two  years,  had  suffered  a  few  months  before  from  ''infantile 
paralysis  or  acute  anterior  poliomyelitis  of  the  right  shoulder,"  leaving  behind 
paralysis  and  wasting,  with  reaction  of  degeneration  in  the  deltoid,  supra- 
spinatus,  and  infraspinatus  muscles.  The  biceps,  brachialis  anticus,  and 
supinator  longus  were  only  sHghtly  affected.  From  dissections  and  experi- 
ments on  monkeys  Harris  and  Low  concluded  that  the  "circumflex"  bundle 
of  nerve  filaments  occupies  the  upper  half  of  the  fifth  root.  In  the  case  under 
discussion  they  made  a  longitudinal  split  in  the  fifth  root,  found  that  the  f aradic 
stimulation  of  the  upper  segment  of  the  nerve  gave  the  very  slightest  contrac- 
tion of  the  biceps  with  definite  weak  contractions  of  the  deltoid  and  triceps, 
while  stimulation  of  the  lower  half  gave  powerful  contractions  of  the  biceps, 
causing  strong  flexion  of  the  forearm,  with  no  contractions  at  all  in  the  deltoid. 
This  being  so,  the  "upper  half  of  the  nerve  was  formed  into  a  flap  having  its 
base  below  (at  the  junction  of  the  fifth  and  sixth  roots)  and  the  free  end  of 
the  flap  was  anastomosed  to  a  split  made  in  the  side  of  the  sixth  root." 

Operations  such  as  this  one  of  Harris  and  Low  have  not  yet  stood  the 
test  of  time,  but  their  possibility  and  plausibility  make  them  deserving  of  atten- 
tion.    In  one  of  his  cases  Kennedy  had  a  most  gratifying  result. 

(B)  Indirect  Method.— r^ft^y'^  Operation.— {"Brit  Med.  Jour.,"  Oct.  17, 
1903.)  In  some  cases  satisfactorily  treated  by  Tubby  no  attempt  was  made  to 
repair  the  damaged  nerves,  but  disability  was  relieved  by  means  of  muscle 
transplantation  or  grafting.     The  operation  is  performed  in  two  sittings: 

(a)  Restoration  of  Elbow  Flexion. — Step  1. — Make  an  incision  four  to  six 
inches  long,  from  the  middle  of  the  back  of  the  upper  arm  downwards  and 
forwards  towards  the  front  of  the  elbow,  and  following  the  course  of  the  mus- 
culo-spiral  groove. 

Step  2. — Expose  and  draw  aside  the  musculo-spiral  nerve.  Demonstrate 
the  outer  part  of  the  triceps  muscle  which  arises  above  and  to  the  outer  side 
of  the  musculo-spiral  groove.  Detach  a  wide  strip  of  the  outer  part  of  the 
triceps  from  its  tendon,  and  separate  it  upwards  for  three  to  four  inches,  leav- 
ing this  strip  or  flap  attached  to  the  rest  of  the  triceps  by  its  upper  extremity. 

Step  3. — Through  the  same  incision  expose  the  lower  end  of  the  biceps.  At 
a  point  about  two  inches  above  the  elbow  make  a  tunnel  through  the  muscle, 
43 


674  NERVES. 

from  behind  forwards.     Flex  the  elbow  to  relieve  tension.     Pull  the  free  end 
of  the  triceps  flap  through  the  tunnel  in  the  biceps  and  fix  it  there  with  sutures. 

Step  4. — Close  the  wound.  Dress.  Immobilize  the  elbow  in  a  position 
of  flexion.     Do  not    permit  any  attempts  at  motion  for  one  month. 

{b)  Restoration  of  Shoulder  Abduction. — Step  i. — From  a  point  one  inch 
below  the  middle  of  the  clavicle  make  an  incision  outwards  to  the  tip  of  the 
acromion  and  then  downwards  for  three  inches.  From  the  tip  of  the  acromion 
make  an  incision  upwards  for  two  to  three  inches.     Reflect  the  flaps  outlined. 

Step  2. — Demonstrate  the  clavicular  portion  of  the  pectoralis  major;  sepa- 
rate it  from  its  attachment  to  the  rest  of  the  muscle;  divide  its  insertion  into 
the  humerus,  thus  forming  a  muscular  flap  attached  to  the  clavicle.  Demon- 
strate and  divide  the  insertion  of  the  trapezius  into  the  clavicle;  separate  the 
corresponding  part  of  the  muscle  from  the  rest  of  the  trapezius  by  splitting  in 
the  direction  of  the  fibres.     Thus  a  second  muscular  flap  is  obtained. 

Step  3. — Bring  the  free  end  of  the  flap  obtained  from  the  pectoralis  major 
upwards  over  the  acromion  process  and  fix  it  into  the  deltoid.  With  sutures 
fix  a  few  fibres  of  the  pectoral  flap  to  the  tip  of  the  acromion  so  as  to  avoid 
slipping.  If  the  flap  is  not  long  enough  to  reach  and  be  united  to  the  deltoid 
satisfactorily,  make  a  vertical  incision  through  the  muscle  to  the  bone,  reflect 
upwards  a  flap  of  periosteum  (as  thick  and  large  as  possible),  and  unite  this 
to  the  end  of  the  pectoral  flap.  Suture  the  end  of  the  flap  obtained  from  the 
trapezius  to  the  side  of  the  pectoral  flap.  The  result  is  a  new  muscle  com- 
posed of  contributions  from  the  pectoralis  major  and  the  trapezius,  inserted 
into  the  humerus  in  imitation  of  the  deltoid. 

Step  4. — Close  the  wound.  Dress.  Immobilize  in  a  position  of  abduc- 
tion. Do  not  put  the  newly  grafted  muscle  on  stretch  for  at  least  a  month. 
After  one  month  begin  exercises  with  caution.  Tubby  has  had  some  excellent 
results  from  this  operation. 

In  certain  cases  of  deltoid  paralysis,  other  than  Duchenne's,  muscle  trans- 
plantation may  be  valuable. 

Hildebrand's  Operation. — Instead  of  changing  the  site  of  insertion 
Hildebrand  has  changed  the  site  of  origin  of  the  pectoralis  major. 

Experiments  have  shown  that  a  muscle  which  has  been  almost  entirely  cut  off 
from  the  circulation  may  be  united  with  the  body  again  and  retain  its  function 
provided  that  its  connection  with  the  central  nervous  system  is  retained  and 
that  the  blood  supply  of  these  nerve  connections  is  intact.  It  is  true  that  the 
majority  of  the  muscle  fibres  degenerate  as  a  result  of  the  sudden  limitation 
of  the  circulation,  but  the  power  of  regeneration  is  completely  preserved. 
These  experiments  teach  that  preservation  of  the  nerve  supply  is  much  more 
important  than  preservation  of  the  vascular  connections  of  a  muscle  used  in 
transplantation.  Hildebrand  used  the  above  knowledge  in  the  following  case: 
A  child,  age  four,  suddenly  became  paralyzed  in  left  shoulder  fifteen  months 
before. 

Examination  showed  complete  loss  of  function  of  the  following  muscles: 


BR.\CHIAL    PALSY. 


675 


Sterno-mastoid  and  trapezius  (n.  accessorius),  deltoid  and  teres  minor  (n. 
axillaris),  serratus  anticus  major  (n.  thoracicus  longus),  infraspinatus  (n. 
suprascapularis) .  Flail  joint.  Arm  hung  loose,  was  rotated  inwards  and 
adducted. 

Operatim. — Step  i. — Make  an  incision  through  the  skin  from  the  sternal 
end  of  the  fourth  rib  upw^ards  to  the  sterno-clavicular  joint,  from  here  outwards 
immediately  above  the  clavicle  to  the  acromion  and  thence  downwards  over 
the  bulge  of  the  shoulder  to  a  point  near  the  insertion  of  the  deltoid.  Reflect 
downwards  the  skin  flap  thus  oudined,  so  as  to  expose  the  pectoralis  major 
and  the  deltoid  very  freely. 


wacic 

nerves 

Pectoral  is 
minor 


Fig.  766. — (^Adapted from  Zuckerkandl.) 

Step  2.^Divide  the  sterno-clavicular  origin  of  the  pectoralis  major  through 
its  tendinous  portion,  i.  e.,  close  to  the  bone.  Separate  the  muscle  com- 
pletely from  the  chest-wall.  With  utmost  care  preserve  the  anterior  thoracic 
nerves  and  the  accompanying  vessels  which  come  from  under  the  clavicle 
above  and  enter  the  deep  surface  of  the  muscle.  (Fig.  /66.)  The  muscle  is 
now  merely  attached  to  the  body  by  its  insertion  into  the  humerus  and  by 
its  vessels  and  nerves. 

Step  3. — Turn  the  flaps  upwards  and  outwards  so  as  to  cover  part  of  the 
deltoid  and  suture  the  divided  origin  of  the  muscle  to  the  outer  third  of  the 
clavicle  and  to  the  acromion  after  preparing  these  bones  by  cutting  a  groove 
in  them.  The  muscle  now  extends  from  the  clavicle  (outer  one-third)  and 
acromion  over  the  apex  of  the  shoulder  to  the  crest  of  the  greater  tubercle  of 
the  humerus,  i.  e.,  it  is  in  position  to  elevate  the  arm. 

Step  4. — Close  the  skin  wound.  Apply  dressings.  Fix  the  arm  in  the 
horizontal  posture  (abduction)  so  as  to  relax  the  implanted  muscle.  At  the 
end  of  six  weeks  the  patient  was  able  to  bring  the  arm  forwards  nearly  to  the 


676 


NERVES. 


horizontal,  and  was  able  to  touch  her  nose  and  the  back  of  her  neck.  ("  Archiv 
fiir  klin.  Chir.,"  Ixxviii,  75.) 

Hoffa's  Operations, — Hoffa  has  devised  measures  similar  to  those  of 
Tubby.     His  report  ("Archiv  fiir  klin.  Chir.,"  Ixxxi,  473)  is  as  follows: 

1.  A.  M.  9.  Right  paralytic  flail  shoulder.     Complete  paralysis,  deltoid. 
Operation. — Separation  of  the  trapezius  from  the  clavicle,  acromion  and 

scapula.  Union  of  the  divided  trapezius  to  the  deltoid,  the  arm  being  com- 
pletely abducted.  Result  good.  The  patient  can  raise  the  arm  almost  to 
the  horizontal,  and  the  function  is  only  slightly  limited. 

2.  F.  K.  2  1/2.  Obstetrical  paralysis,  right  arm.  Arm  hangs  loosely 
downwards;  internal  rotation  so  marked  that  the  elbow  points  forwards. 

Operation. — Division  of  the  insertion  of  the  very  tense  pectoralis  major. 
Resection  of  a  part  of  the  head  of  the  humerus.  Transplantation  of  the  tra- 
pezius into  the  deltoid.  Result  good.  The  internal  rotation  corrected;  the 
arm  can  be  raised  nearly  to  the  horizontal  so  that  the  hand  is  easily  put  to 
the  mouth. 

III.  Nerve  anastomosis  for  anterior  poliomyelitis.  Since  it  has  been  shown 
that  a  paralyzed  nerve  which  is  functionally  separated  from  its  motor  centre 
is  still  able  to  carry  impulses  if  anastomosed  with  a  functionally  intact  neigh- 
boring nerve,  endeavors  have  been  made  by  several  surgeons  to  supply  nerve 
stimuli  to  the  muscles  paralyzed  as  a  result  of  anterior  poliomyelitis,  by  means 
of  nerve  anastomosis.  As  very  great  and  often  unexpected  recovery  may  take 
place  after  paralysis  from  anterior  poliomyelitis  it  is  usually  considered  wise 
to  wait  6  months  or  more  before  deciding  an  operative  interference. 

Fig.  767  (Murphy)  shows  a  good  type  of  operation. 

The  accompanying  table  compiled  by  Murphy  shows  what  has  been  done 
by  nerve  anastomosis  in  infantile  palsy. 

NERVE  ANASTOMOSIS  FOR  THE  CURE  OF  ANTERIOR 
POLIOMYELITIS. 


Author  and 
Publication 


Condition  and  Ex- 
tent of  Paralysis 


Operation 


Result 


Peckham.  Provi- 
dence Med.  Jour., 
1900,  p.  5. 


Anterior  poliomyeli- 
tis; 10  years' 
standing. 


Section  of  healthy 
fibres  and  anas- 
tomosis with  dis- 
eased fibres. 


Extension    of    toes    6 
weeks  later. 


W.  G.  Spiller  and 
Charles  H.  Frazier. 
Jour.  Am.  Med. 
Assn.,  Jan.  21, 
1905. 


(a)  Paralysis  of  an- 
terior tibial  muscle 
(limited  paralysis, 
anterior  poliomye- 
litis). 

(b)  Paralysis  con- 
fined to  the  pero- 
neal muscles;  2 
years'  standing. 


Branches  supplying 
tibial  muscles 
rushed  into  mus- 
culocutaneous. 

Anastomosis  between 
anterior  tibial 
nerve  and  muscu- 
locutaneous. 


(a)  Gait  nearly  nor- 
mal, and  the  child 
can  draw  up  the 
inner  side  of  foot 
almost  with  normal 
power. 

(b)  No  improvement 
after  4  weeks.  No 
change  in  the  elec- 
trical reaction. 


DISLOCATION    OF    ULNAR    NERVE. 


677 


Author  and 
Publication 


James     K. 
Internat. 
14th    set., 
P-  159- 


Young. 
Clinics, 
vol.  iv, 


Condition  and  Ex- 
tent of  Paralvsis 


Paralysis,  limited  to 
anterior  tibial  mus- 
cle only. 


Operation 


Anastomosis  between 
the  branch  supply- 
ing anterior  tibial 
muscle  and  mus- 
culocutaneous by 
inserting  the  form- 
er into  slit  formed 
in  the  latter. 


Result 


Improvement  at  time 
of  presentation  of 
patient. 


John    B.        Murphy 
(present  paper). 


Paralysis  limited  to 
anteriol  tibial 
muscle  and  exten- 
sor communis  digi- 
torum;  5  years' 
standing. 


Nerve  anastomosis 
combined  with  ten- 
don-plastic. 

(a)  Anastomosis  be- 
tween external  and 
internal  popliteal. 

(b)  Elongation  of 
flexors,  shortening 
of  extensors. 


Great    improvement. 
Extension       volun- 
tar}'.     Electrical  re- 
sponse in  extensors. 
Patient     walks^ — 


Kader  (Cracow,  Po- 
land.) Quoted  in 
Chipault's  Etat  ac- 
tuel  de  la  chirur- 
gie  nerveuse,  vol. 
ii,  p.  202. 


Four  cases  of  infan- 
tile paralysis  with 
equino-varus  (par- 
alytic). 


Anastomosis  between 
external  and  inter- 
nal popliteal;  also 
tendon  plastic, 
elongation  of  llex- 
ors  and  shortening 
of  extensors. 


One  success;  one  fail- 
ure, one  improve- 
ment, one  in  con- 
valescence at  time 
of  publication. 


P.  Hackenbruch 
(Wiesbaden).  Proc. 
Germ.  Surg.  Cong., 
1903,  vol.  xxxii,  p. 
238. 


Infantile  paralysis. 


Implantation  of  one-  Some  improvement  at 

third  of  tibial  nerve  the  time  of  commu- 

into    the    peroneal  nication. 
nerve. 


John  B.  Murphy. 


Infantile  paralysis. 
Paralysis  of  pero- 
neus  tertius  and 
brevis. 


(a)  Transplantation 
of  two-fifths  of 
tendo  achilHs  into 
slit  tendon  of  long 
and  short  peroneal. 

(b)  Implantation  of 
two-thirds  of  pero- 
neal branch  of 
musculocutane  o  u  s 
into  anterior  tibial. 


Too    early    for 
cuiar  return. 


IV.  Dislocation  of  Ulnar  Nerve  at  Elbow. — Momburg  (''Archiv  f. 
kiln.  Chir.,"  Ixx,  215)  has  shown  that  the  ulnar  nerve  is  frequently  thrown 
out  of  its  groove  on  the  inner  epicondyle,  especially  during  elbow  flexion ;  that 
this  is  entirely  unimportant  unless  the  nerve  is  irritated;  that  when  there  are 
irritation  and  pain,  the  only  cure  is  by  operation.  Several  operations  have 
given  good  results.  Croft  sutured  the  nerve  to  the  triceps  tendon  and  the 
fibrous  tissue  covering  the  bone.  McCormac  isolated  the  nerve  and  fixed 
it  by  loops  of  kangaroo  tendon  to  the  triceps  tendon.  Several  surgeons  have 
formed  flaps  of  fascia  or  even  of  bone  and  periosteum  (from  the  epicondyle) 


678 


NERVES. 


and  with  these  covered  the  nerve  in  its  groove.  Momburg  splits  the  triceps 
tendon  and  part  of  the  muscle  longitudinally;  at  the  upper  end  of  the  split  he 
divides  the  muscles  to  the  ulnar  side  of  the  split,  pulls  the  flap  thus  formed 
around  the  nerve,  and  sutures  the  muscle  in  its  normal  position.  The  nerve 
now^  passes  through  the  triceps  and  cannot  be  dislocated. 


Fig.  767. — {Murphy,  "Surg.  Gyn.  Obst.'') 


ALTERATIVE  OPERATIONS  ON  NERVES. 

The  most  important  methods  employed  to  modify  the  structure  or  condi- 
tion of  nerves  are  nerve-stretching  and  the  disassociation  of  fibres.  In  the 
latter  operation,  after  the  nerve  is  exposed,  its  fibres  are  separated  one  from 
the  other  by  blunt  dissection;  the  indications  and  results  are  supposed  to  be 
similar  to  those  of  nerve-stretching,  but  the  operation  does  not  appeal  to  most 
surgeons.  Nerve-stretching  has  been  used  in  many  affections.  Its  employ- 
ment seems  most  valuable  in  neuritis  (e.  g.,  sciatica),  perforating  ulcer  of  the 
foot,  varicose  ulcer  (the  ulcer  being  dystrophic,  i.  e.,  due  to  a  lack  of  nerve 
stimuli  to  the  area  affected),  angio-neurotic  changes  in  the  lower  extremity, 
muscular  spasm,  e.  g.,  in  facial  region.     Various  explanations  of  the  modus 


NERVE    STRETCBING.  679 

operandi  of  nerve-stretching  have  been  given,  the  most  reasonable  being  the 
breaking  down  of  adhesions  and  the  production  of  local  hyperemia. 

Sciatic  Nerve. — The  most  suitable  cases  for  nerve-stretching  are  those  of 
sciatica  due  to  exposure  to  cold  and  wet  and  in  which  the  pain  is  limited  to 
the  distribution  of  the  nerve. 

The  Operation. — Lay  the  patient  in  the  prone  position.  Note  by  palpa- 
tion the  tuber  ischii  and  the  great  trochanter,  midway  between  these  points 
make  a  4-inch  longitudinal  incision  downwards  from  a  point  just  above  the 
gluteal  fold.  The  centre  of  the  cut  corresponds  to  the  lower  edge  of  the  gluteus 
maximus  which  is  at  a  level  lower  than  the  fold  of  the  buttock.  Divide  the 
fascia. 

Demonstrate  the  edge  of  the  gluteus  maximus  running  downwards  and 
outwards,  and  retract  it  upwards.  Feel  for  and  retract  outwards  the  ham- 
string muscles  after  relaxing  them  by  bending  the  knee. 

The  nerve  is  now  exposed.  Hook  the  nerve  up  with  the  finger  and  apply 
traction  both  upwards  and  downwards.  The  traction  must  be  steady  and 
strong.  Enough  power  to  lift  the  limb  may  commonly  be  exerted  without 
danger,  as  the  sciatic  nerve  can  withstand  a  strain  of  about  80  pounds.  Re- 
place the  nerve  in  its  bed.     Close  the  wound. 

Internal  Popliteal  Nerve  (Tibial  Nerve). — Step  i. — From  the  centre  of 
the  popliteal  space  make  a  3  1/2  inch  incision  downwards  over  the  interval 
between  the  two  heads  of  the  gastrocnemius.  Retract  the  short  saphenous 
vein  and  nerve.     Divide  the  deep  fascia. 

Step  2. — Separate  the  two  heads  of  the  gastrocnemius.  Flex  the  knee  to 
relieve  tension.  Follow  the  short  saphenous  vein  into  the  popliteal  space;  it 
goes  directly  to  the  popliteal  vessels,  superficial  to  which  the  nerve  lies. 

Step  3. — Hook  up  the  nerve  vdih  the  finger.  Stretch  it  by  pulling  upwards 
and  downwards. 

External  Popliteal  Nerve  (Commonly  Peroneal). — Treves  thus  describes 
the  exposure  of  this  nerve: 

" Anatofjiy. — The  external  popliteal  or  peroneal  nerve  follows  the  outer 
side  of  the  popliteal  space,  lying  close  to  the  biceps.  Passing  over  the  outer 
head  of  the  gastrocnemius,  between  it  and  the  biceps,  the  nerve  reaches  the 
neck  of  the  fibula,  and  crosses  that  bone  beneath  the  fibres  of  the  peroneus 
longus  muscle.  The  nerve  may  be  easily  felt,  when  the  knee  is  a  little  flexed, 
as  a  loose  rounded  cord,  lying  just  behind  the  biceps,  as  it  nears  the  head  of 
the  fibula. 

"Operation. — The  patient  lies  upon  the  sound  side,  with  a  sufficient  tending 
to  the  prone  position  to  well  expose  the  outer  aspect  of  the  knee.  The  knee- 
joint  is  extended.  An  incision,  one  inch  and  a  half  in  length,  is  made  parallel 
with  and  immediately  posterior  to  the  tendon  of  the  biceps.  The  cut  should 
be  so  placed  that  its  upper  half  is  in  relation  with  the  tendon  while  its  lower 
half  is  over  the  fibula.  The  skin  and  deep  fascia  having  V)een  divided,  the 
biceps  tendon  is  exposed.     The  knee  should  now  be  a  little  flexed  and  the 


68o  NERVES. 

nerve  sought,  close  to  the  point  at  which  the  tendon  reaches  the  head  of  the 
fibula.  A  narrow  and  unduly  prominent  ilio-tibial  band  has  been  mistaken 
for  the  biceps  tendon." 

Facial  Nerve. — The  facial  nerve  has  been  successfully  stretched  in  the 
treatment  of  spasmodic  tic.  This  operation  is  highly  recommended  by  Kocher. 
Exposure  of  the  facial  nerve  is  sufficiently  described  in  the  chapter  on  nerve 
anastomosis. 

Exposure  of  Musculo-spiral  (Radial)  Nerve. — This  nerve  requires 
exposure  and  treatment,  in  most  instances,  because  of  injury  or  compression 
due  to  fracture  of  the  humerus.  As  the  anatomic  relations  are  sure  to  be 
changed  at  the  site  of  injury  it  is  wise  to  expose  the  nerve  either  below  or  above 
and  to  follow  it  to  the  injured  point. 

Exposure  of  Nerve  in  Lower  Part  of  Upper  Arm. — Step  i.— Make  an 
oblique  incision  about  3  inches  long  in  the  groove  between  the  supinator  longus 
and  brachialis  anticus  muscles.  The  whole  of  this  incision  is  in  the  lower 
third  of  the  arm.  Divide  the  deep  fascia.  Separate  the  two  muscles  (sup. 
longus;  brachialis  ant.)  and  expose  the  nerve  which  lies  between  them. 

Step  2. — Follow  the  nerve  upwards  to  the  site  of  injury  being  careful  not 
to  injure  the  companion  artery.  In  a  case  operated  on  by  the  author  the  nerve 
was  stretched  as  a  thin  fibrous  band  over  a  sharp  angle  of  bone  for  a  distance 
of  about  1/4  inch.  All  objectionable  pieces  of  bone  were  cut  away;  the  nerve 
which  was  adherent  to  the  bone  was  freed ;  a  layer  of  brachialis  anticus  muscle 
was  stitched  between  the  nerve  and  the  bone  and  the  wound  closed.  The 
result  was  perfect  after  some  months  of  appropriate  treatment.  If  for  any 
reason  it  is  impossible  or  improper  to  find  the  nerve  below  the  site  of  injury, 
expose  it  above. 

Exposure  of  Nerve  in  Upper  or  Middle  Part  of  Arm.— From  a  point  a 
little  lower  than  the  posterior  axillary  fold  make  an  incision  downwards  over 
the  interspace  between  the  long  head  and  the  external  (lateral)  head  of  the 
triceps.  Separate  the  two  heads  of  the  muscle  by  blunt  dissection  down  to 
the  bone  against  which  the  nerve  lies  accompanied  by  the  profunda  artery. 


CHAPTER  LX. 


PRINCIPLES  OF  PLASTIC  SURGERY. 


v^^ 


^^  ^e\^^^'-i"-^J'}cjs^^ 


Plastic  operations  are  such  as  are  undertaken  to  close  up  or  fill  defects 
resulting  from  errors  in  the  development  (hare-lip,  etc.)  or  from  the  destruction 
of  tissues  by  disease,  operation,  or  accidental  injur}'.  While  plastic  operations 
are  applied  to  each  and  every  kind  of  tissue  (bone  transplantation,  tenoplasty, 
neuroplasty,  etc.),  yet  in  most  of  them  the  skin  plays  the  chief  role. 

Do  not  undertake  plastic  operations  in  the  debilitated  or  in  those  with 
active  disease  present  {e.  g.,  suppuration,  syphilis,  etc.). 

The  two  main  principles  at  the  base  of  all  plastic  work  are:  (a)  Proper 
preparation  or  vivification  of  the  tissues  to  be  united;  (b)  thorough  relief  of  ten- 
sion.    Failure  to  carry  out  these  principles  leads  to  certain  disappointment. 

When  the  defect  is  oval  but  not  very  extensive  and  the  neighboring  skin  is 
not  firmly  bound  to  the  deeper  structures,  the  edges  of  the  oval  may  be  brought 
together  directly  and  sutured.  If  on 
attempting  approximation  tension  makes 
itself  evident,  this  tension  must  be  re- 
lieved. Tension  may  be  relieved  by 
burrowing  with  knife  or  scissors  between 
the  skin  and  the  deep  fascia,  thus  under- 
mining the  skin  all  around  the  defect 
(Fig.  768).  In  some  localities,  e  g.,  the 
pectoral  region,  very  large  defects  may 
be  thus  obliterated.  Often  this  burrow- 
ing must  be  supplemented  by  making  a 
cut  through  the  skin  parallel  to  and  on 
one  or  both  sides  of  the  defect.  Such 
relaxation  incisions  should  be  in  positions 
where  their  scar  will  be  more  or  less 
hidden.  When  the  defect  is  square-shaped,  it  may  be  closed  as  shown  in  Fig. 
769.  Large  defects  require  other  means  of  treatment,  either  being  closed  by 
skin-grafting  or  by  the  use  of  pedunculated  flaps  of  healthy  skin,  obtained 
preferably  in  the  near  neighborhood,  occasionally  from  more  remote  parts. 
The  skin  chosen  to  form  the  flaps  must  be  such  as  to  match  that  lost.  It  would 
not  gratify  a  patient  much  to  have  a  successful  rhinoplasty  performed  on  him  if 
the  hairy  scalp  was  used  to  supply  the  necessary  skin  for  the  nose.  The  objec- 
tion to  many  of  the  operations  for  ectopia  vesicae  or  for  epispadias  is  that  skin 
capable  of  growing  hair  is  used  to  line  the  new  bladder  or  urethra.     Hairless 

681 


Fig.  768. 


682 


PRINCIPLES    OF    PLASTIC    SURGERY. 


skin  is  often  used  to  replace  lost  mucous  membrane  but  if  healthy  mucous 
membrane  can  be  obtained,  such  is  far  better.  The  flaps  should  consist  of  the 
whole  thickness  of  the  skin,  but  without  too  much  subcutaneous  fat  attached 
to  them;  they  ought  to  be  about  one-sixth  larger  than  the  defect  they  are  to 
fill,  and  should  have  a  pedicle  through  which  nourishment  is  freely  supplied. 
Twisting  of,  or  tension  on  the  pedicle  occludes  its  blood-vessels,  cutting  off 
nourishment  and  impeding  the  natural  drainage;  hence  it  is  necessary  in 
tracing  out  the  flap  to  do  so  in  such  a  position  that  it  can  be  fixed  in  its 
new  location  without  running  these  hazards.  Part  or  all  of  a  skin-flap, 
even  with  a  good  pedicle,  and  with  its  raw  surface  in  contact  with  a  cor- 
responding healthy  raw  surface,  often  fails  to  live.  After  the  lapse  of  a 
few  hours  the  surface  becomes  discolored,  edematous,  blisters  form,  and 
death  of  the  tissues  takes  place.  This  death  is  not  from  want  of  nourishment; 
it  is  from  want  of  normal  absorption  or  drainage  from  the  flap.     The  drainage 


A 


D 


\ % 


"^-^ 


-t ^ 


is  of  even  more  importance  than  the  nourishment  obtained  through  the  pedicle. 
Under  similar  circumstances  a  flap  of  skin  completely  detached  from  the  body 
and  implanted  into  a  defect  (Wolf's  grafts)  lives  and  does  not  show  the  above 
phenomena.  This  is  due  to  the  fact  that  there  is  no  damming  up  of  lymph 
in  the  detached  portion  of  skin.  The  grafted  skin  soon  becomes  united  to  its 
new  bed,  thus  obtaining  a  sufficiency,  but  not  an  excess  of  nourishment. 
C.  H.  Mayo  scarifies  the  surface  of  flaps  which  are  provided  with  pedicles, 
thus  providing  for  immediate  lymph  drainage  and  avoiding  the  dangers  of 
necrosis  from  lymph  stasis.  This  scarification  need  not  be  deep;  mere 
scratches  sufiice. 

Sometimes  flaps  are  provided  with  two  pedicles — "visor-shaped"  flaps. 
A  good  example  of  this  variety  is  seen  in  Regnier's  operation  for  cancer  of  the 
lower  lip. 

Fear  may  be  entertained  as  to  the  viability  of  a  flap  if  it  is  transferred  to 
its  new  site  as  soon  as  it  is  formed,  and  thus  in  some  cases  it  is  wise  to  trace 
out  the  flap,  separate  it  from  the  deep  structures,  but  leave  it  attached  at  both 
ends;  the  bridge  of  skin  thus  formed  must  be  kept  separated  from  the  sub- 
jacent tissues  by  a  layer  of  oiled  silk.  After  about  two  or  three  weeks  one  of 
its  pedicles  is  divided  and  the  flap  put  in  place  (Fig.  770).  This  plan  (Croft's) 
is  specially  suitable  when  the  flaps  required  are  long  and  narrow. 

Instead  of  pedunculated  flaps,  areas  of  skin  entirely  detached  from  their 


SKIN   GRAFTING.  683 

normal  connections  may  be  used.  This  is  truly  skin-grafting.  The  grafts 
may  be  obtained  from  the  patient  himself,  from  a  recently  amputated  healthy 
limb,  or  from  obliging  friends.  Grafts  obtained  from  animals  (rabbits,  frogs) 
have  been  employed,  but  when  used  after  the  Thiersch  method,  even  if  they 
have  adhered  to  the  raw  surface,  they  have  not  reproduced  epithelium  and 
have  been  ultimately  absorbed. 

Wolf's  Grafts. — Wolf,  of  Glasgow,  devised  the  following  method  of  repair- 
ing recent  defects,  especially  in  the  eyelids: 

On  some  suitable  region — the  forearm,  inner  side  of  upper  arm,  or  thigh — 
trace  with  the  scalpel  an  area  of  skin  at  least  one-sixth  larger  than  the  defect 
to  be  filled  and  of  suitable  shape.     Quickly  and  completely  separate  the  flap 
outlined   from  the  subjacent  tissues.       With  the  scissors 
carefully  remove  all  fat  from   the  under  surface  of  the 
graft;  in  fact,  trim  this  surface  until  the  pale,  deep  surface 
of  the  cutis  vera  is  visible.      Fit  the  graft  into  the  defect 
and  hold  it  accurately  in  place,  either  by  a  few  fine  sutures 
or  by  suitable  dressings.      In  the  repair  of  defects  in  the 
eyelid  the  writer  has  often  seen  the  Wolf  graft  sutured  in 
place  and  protected  by  a  few  layers  of  gold-beater's  skin, 
which,  when  dry,  acts  as  an  efiicient  splint  to  the  part. 

Grafts  such  as  above  are  usually  employed  to  cover  fig.  770. 

raw   areas    resulting   from   operations  and  not  to  cover 
granulating    surfaces.      It  is  of  prime  importance  that  hemorrhage  be  com- 
pletely .stopped,  otherwise  effused  blood  will  lift  the  graft  from  its  bed  and 
prevent  adhesions. 

Thiersch's  Graft.— Thiersch  suggested  the  use  of  grafts  consisting  of 
epidermis,  corresponding  in  thickness  to  the  covering  of  a  blister  and  cut 
from  some  suitable  region  in  as  large  strips  as  possible.  This  is  the  most 
common  and  convenient  method  of  skin-grafting.  The  grafts  may  be  applied 
to  a  fresh  wound,  e.  g.,  open  wound  left  after  amputation  of  the  breast,  or  to 
any  clean  granulating  surface.  When  a  granulating  surface  is  to  be  covered 
by  grafts,  it  must  be  prepared  by  thorough  cleansing  and  the  removal  of  exuber- 
ant granulations  by  means  of  rubbing  with  gauze  or  by  the  sharp  spoon.  All 
bleeding  must  have  ceased,  whether  the  wound  is  recent  or  granulating.  If 
oozing  of  blood  persists,  the  wounded  surface  must  be  covered  by  a  protective 
layer  of  rubber  tissue,  silver-foil,  or  such  like  material,  over  which  sterile 
gauze  is  applied,  and  the  skin-grafting  put  off  until  the  next  day. 

The  grafts  are  generally  obtained  from  the  inside  of  the  thigh.  If  the  skin 
to  be  employed  is  hair}-,  shave  the  hair.  As  the  portion  of  epidermis  to  be 
taken  is  too  thin  to  contain  any  hair-bulbs,  no  hair  will  be  grafted,  no  matter 
from  what  region  the  graft  is  obtained.  Cleanse  the  area  selected.  With  the 
hands,  McBurney's  tractor,  or  a  paper-knife  make  the  skin  tense.  Shave  off  the 
thinnest  possible  layer  of  epidermis  with  a  very  keen  razor,  moistened  with 
salt  solution  (Halsted  uses  an  amputation  knife).     This  forms  the  graft,  and 


684 


PRINCIPLES    OF    PLASTIC    SURGERY. 


should  be  as  large  as  possible.  Carry  the  graft,  lying  in  folds  on  the  razor 
blade,  to  the  wound.  Keep  it  moist  with  salt  solution.  Hold  the  sharp  edge 
of  the  blade  close  to  the  wound.  With  a  needle  pull  the  end  of  the  graft  gently 
on  to  the  wound,  temporarily  fixing  it  there;  as  the  blade  is  slowly  pulled  away 
parallel  to  the  wound  the  graft  smoothly  slips  off  it  and  lies  flat  on  the  wound. 
If  there  are  any  little  folds  in  the  graft,  get  rid  of  them  with  needles  in  the  same 
manner  as  is  done  when  spreading  sections  of  tissue  on  the  slide  for  micro- 


Fig.   771. 

scopic  work.  Sometimes  if  the  graft  becomes  tangled  on  the  razor  blade  it  is 
well  to  put  it  in  a  basin  of  salt  solution  and  float  it  on  to  a  piece  of  oiled  silk. 
The  oiled  silk  with  the  graft  lyng  smoothly  on  it  is  laid  (with  the  graft  under) 
on  the  wound,  the  edge  of  the  graft  is  held  in  place  on  the  wound  with  a 
needle,  and  the  oiled  silk  removed  gently,  leaving  the  graft  in  the  position 
desired. 


Fig.  772. 

When  the  whole  wound  is  covered  with  grafts,  place  over  them  strips  of 
rubber  tissue  or  of  silver-foil,  and  outiside  this  the  ordinary  gauze  dressings. 
The  dressings  ought,  if  possible,  to  remain  unchanged  for  a  week;  when  they 
are  removed,  the  rubber  tissue  or  silver-foil  prevents  their  pulling  the  delicate 
epithelium  away  with  them.  No  antiseptic  lotions  ought  to  be  employed,  only 
salt  solution.     The  same  kind  of  dressings  must  be  applied  until  the  healing 


PLASTIC   SURGERY. 


685 


A 


\ 


.t     t    t 


Fig.  773,  a,  B,  C 


Fig.  776,  A,  B. 


Fig.  774,  A,  B,  C. 


686  PRINCIPLES    OF    PLASTIC    SURGERY. 

process  is  complete.  Very  large  surfaces  can  be  made  to  heal  in  a  short  time 
by  the  Thiersch  method  of  skin-grafting. 

When  possible  it  is  far  better  to  avoid  the  use  of  any  dressing  or  tissue 
applied  to  the  grafted  area  which  should  be  left  freely  exposed  to  the  air.  To 
protect  the  wound  against  flies  and  mechanical  irritati'on,  it  may  be  surrounded 
by  a  thick  wall  of  cotton  or  such  like  material  which  supports  a  roof  of  fine 
wire  netting  (mosquito  screen)  (Fig.  771).  Some  surgeons  have  advised  the 
use  of  a  plate  of  celluloid  instead  of  the  wire  netting,  but  this  prevents  the  desired 
free  circulation  of  air. 

Carl  Haeberlin  (Bad  Nauheim)  finds  that  all  granulating  wounds  heal  best 
when  exposed  to  the  direct  rays  of  the  sun  (without  any  interposed  material)  for 
about  two  or  three  hours  daily;  during  the  rest  of  the  day  he  covers  the  wounds 
loosely  with  gauze  ("Munchener  med.  Woch.,"  15  Oct.,  1907). 

Denuded  areas  on  the  hand  or  forearm  may  be  covered  with  skin  by  the 
following  efficient  but  distinctly  uncomfortable  method:  If  the  defect  is  on 
the  back  of  the  hand  or  forearm,  choose  a  place  on  the  front  of  the  abdomen 
or  chest  where  the  hand  or  forearm  may  lie  and  be  supported  without  too  great 
strain.  Through  the  skin  of  the  trunk  make  two  parallel  incisions  and  under- 
mine the  skin  between  them,  thus  forming  a  flap  with  two  pedicles  (Fig.  772). 
Push  the  hand  under  the  flap  and  adjust  and  suture  the  flap  to  the  denuded 
area.  Apply  dressings,  and  with  adhesive  plaster  fix  the  hand  and  arm  to  the 
trunk.  When  union  has  taken  place  between  the  flap  and  the  denuded  area, 
divide  the  pedicles,  close  the  abdominal  wound  in  the  usual  manner,  trim  the 
flap,  and  complete  its  union  to  the  denuded  area.  If  the  denuded  area  is  on 
the  palmar  aspect  of  hand  or  forearm,  the  flap  must  be  made  on  the  back  of 
the  trunk.  The  following  diagrams  illustrate  better  than  words  a  few  methods 
by  which  defects  can  be  filled  by  means  of  skin-flaps  (Figs,  773  to  777). 
Special  plastic  operations  have  been  considered  in  the  sections  devoted  to  the 
surgery  of  various  individual  conditions  and  regions. 


CHAPTER  LXI. 
LIGATURES  AND  SUTURES. 

I.  Non-absorbable. — The  principal  non-absorbable  ligatures  or  sutures 
are:  (a)  Silk;  (b)  Pagenstecher's  or  Braun's  celluloid  hemp;  (c)  silkworm-gut; 
(d)  horse-hair;  (e)  wire  (silver,  gold,  aluminium-bronze).  All  the  above  ma- 
terials are  strong,  of  uniform  size,  capable  of  being  easily  and  securely  tied  or 
fastened,  and  sterilized  by  being  boiled  or  steamed. 

Silk  is  the  material  most  commonly  used  for  intestinal  sutures  and  for  non- 
absorbable ligatures.  Celluloid  hemp  (in  the  smaller  sizes)  possesses  all 
the  advantages  of  silk,  and,  in  addition,  it  has  less  capillarity,  and  being  stiflfer, 
can  be  readily  threaded  into  fine  needles  even  when  wet.  These  two  peculiar- 
ities are  of  great  value  in  operations  on  the  intestine.  The  want  of  capillarity 
pervents,  to  some  extent  at  least,  any  infection  passing  along  the  thread,  as 
intestinal  sutures  very  commonly  include  part  of  the  mucosa  even  when  intro- 
duced with  the  greatest  care.  The  convenience  of  being  able  to  thread  a 
needle  with  the  wet  material  is  self-evident.  Celluloid  hemp  is  stronger  than 
silk,  but  its  surface  is  not  so  smooth.  Thick  celluloid  hemp  ligatures  are  not 
so  easily  drawn  into  a  tight  knot  as  are  silk  ones  and  possess  no  advantage  over 
the  latter.  Braun's  thread  is  smooth  and  easily  knotted.  For  sterilization 
celluloid  hemp  requires  to  be  boiled  longer  than  does  silk. 

The  most  convenient  sizes  of  silk  or  hemp  are  Nos.  i,  2,  3,  and  4.  For 
intestinal  sutures  and  the  ligature  of  small  vessels,  Nos.  i  and  2  are  e.xcellent. 
No  4  is  used  for  tying  large  pedicles. 

Preparation  of  Silk  or  Heynp. — Wind  the  thread  on  glass  spools  or  tubes, 
preferably  in  one  layer.  Boil  in  water  or  4  per  cent,  soda  solution  for  fifteen 
or  thirty  minutes  (along  with  the  instruments).  Soak  in  corrosive  sublimate 
solution  i:ioco.  The  advantage  of  using  the  antiseptic  solution  is  that  it 
inhibits  the  growth  of  any  bacteria  which  may  accidentally  gain  access  to  the 
ligature  during  the  operation. 

Kocher  is  the  most  enthusiastic  advocate  of  silk.  He  prepares  his  liga- 
tures as  follows:  Soak  the  silk  in  ether  for  twelve  hours;  then  in  alcohol  for  a 
like  period.  Boil  for  ten  minutes  in  a  1:1000  solution  of  sublimate  (the  subli- 
mate solution  must  neither  be  colored  or  acidulated).  Use  the  silk  directlv 
from  the  sublimate  solution.  As  pulling  thread  between  the  fingers  of  the 
operator  is  liable  to  infect  it,  Kocher  always  wears  gloves  when  tying  ligatures, 
even  when  he  does  not  wear  them  for  the  other  steps  in  the  operation. 

\Mien  silk  is  to  be  used  for  intestinal  work,  it  may  be  sterilized  by  steam,  and 
being  dry,  is  easily  threaded  on  needles.  If  to  be  sterilized  by  boiling,  the 
requisite    numbers  of    needles    should  be  threaded  beforehand  and  stitched 

687 


688  LIGATURES   AND    SUTURES. 

into  a  towel  in  such  a  manner  that  they  can  be  easily  pulled  out  but  cannot 
become  entangled  while  being  boiled. 

Silkworm-gut. — This,  the  common  fishing  gut,  is  prepared  from  the  silk 
worm  when  it  has  got  into  condition  to  begin  spinning.  The  material  used  is, 
in  fact,  the  silk  before  it  is  spun.  Silkworm-gut  is  an  ideal,  smooth,  strong, 
non-porous,  non-absorbable  suture.  It  is  easily  sterilized  by  boiling,  which 
at  the  same  time  softens  it  and  renders  it  easy  to  tie.  If  used  dry,  the  gut  is 
hard  and  too  brittle  to  tie.  It  may  be  obtained  in  various  sizes,  from  the 
thick  and  very  strong  gut  used  by  salmon  fishers  to  the  extremely  fine  "drawn 
gut"  of  the  English  dry  fly  fishermen. 

Horse-hair  possesses  the  advantages  of  fine  silkworm-gut,  but  is  better 
in  that  its  elasticity  prevents  cutting  of  the  tissues.  It  is  ideal  material  for 
fine  skin  sutures,  as  it  leaves  little  scar.  It  is  prepared  for  use  by  a  thorough 
washing  in  soap  and  water  and  then  by  boiling. 

Silver  Wire. — This  is  the  most  common  suture  used  for  uniting  bones. 
Some  surgeons  use  it  extensively  for  buried  sutures.  Its  ends  are  easily  secured 
by  twisting.  Sterilization  is  effected  by  boiling.  The  metallic  silver  is  an 
antiseptic  per  se. 

II.  Absorbable  Ligatures    and  Sutures. — (a)  Catgut;  (b)  Tendon. 

Catgut. — The  most  common  absorbable  ligature  is  made  from  the  sub- 
mucous coat  of  the  intestine  of  sheep.  The  best  catgut  comes  from  Germany 
and  Sweden.  The  American  sheep  suffer  from  some  intestinal  disease  which 
renders  their  submucosa  useless  for  the  manufacture  of  catgut.  The  most 
convenient  sizes  of  catgut  are  Nos.  o,  i,  2,  3.  No.  4  is  occasionally  of  service, 
but  is  very  thick. 

Catgut  may  be  used  plain  or  may  be  treated  with  some  material  which 
renders  its  absorption  by  the  tissues  more  slow  (chromic  acid,  formalin). 
There  are  a  very  great  number  of  methods  by  which  sterilization  may  be 
effected;  only  a  few  of  these  will  be  detailed  here.  Several  manufacturers 
prepare  reliable  catgut  in  convenient  receptacles,  e.  g.,  in  hermetically  sealed 
glass  tubes,  in  air-tight  envelopes,  etc.  Such  catgut  is  usually  sterilized  by  dry 
heat  in  the  fractional  method.  The  process  is  more  or  less  complicated  and 
will  not  be  described,  as  simpler  and  equally  efficacious  methods  are  available. 
The  chromicized  catgut  of  commerce  is  too  thoroughly  chromicized;  it  remains 
too  long  unaffected  by  the  tissues  and  should  be  discarded.  The  cumol 
method  of  sterilization  seems  to  be  reliable,  but  requires  considerable  experi- 
ence to  be  carried  out  in  safety.  Bartlett's  iodized  catgut  is  very  reliable  and 
may  be  obtained  ready  for  use  in  tubes. 

Preparation  of  Catgut. — Wind  the  catgut  in  a  single  layer  on  glass  tubes. 
In  doing  this  it  is  very  important  to  rotate  the  tubes,  and,  holding  the  gut 
tight,  allow  it  to  be  wound  on  to  the  tube.  If  one  twists  the  gut  on  to  the 
tube,  as  it  passes  through  the  fingers  its  fabric  is  liable  to  become  untwisted 
and  its  strength  ruined.  Fasten  the  end  of  the  thread  so  that  it  will  not  come 
undone. 


CATGUT.  689 

Methods  oj  Sterilization. ^{[)  Elsberg's  method  (modified).  Make  a  sat- 
urated solution  of  sulphate  of  ammonium  in  water.  Boil  this  solution  and 
see  that  it  is  saturated  while  boiling.  Boil  the  catgut  in  this  for  twenty  minutes. 
With  sterile  forceps  place  the  gut  in  sterile  water  or  antiseptic  solution  to  remove 
the  sulphate  of  ammonium.  This  does  not  consume  more  than  a  minute. 
Preserve  the  gut  in  alcohol  or  in  a  saturated  solution  of  iodoform  in  alcohol 
and  ether.  Elsberg  before  boiling  soaks  the  gut  for  twenty-four  hours  in  a 
mixture  of  chloroform  and  ether.     This  is  unnecessary. 

(II)  Claudius'  method:  (I,  KI,  catgut).  Soak  the  gut  (wound  on  tubes) 
for  eight  days  in  the  following  solution:  Iodine,  i  part;  iodide  of  potassium, 
I  part;  water,  100  parts.  The  gut  is  now  ready,  and  may  be  used  directly 
from  the  solution  or  after  washing  in  sterile  water  or  some  antiseptic  solution. 
The  author  prefers  using  it  directly  from  the  iodine  solution.  It  is  claimed 
that  the  catgut  may  be  kept  indefinitely  in  the  solution,  but  this  is  incorrect. 

Salkindsohn  modifies  the  above  in  a  happy  fashion  by  using  a  mixture  of 
tincture  of  iodine  i  part  in  15  parts  of  proof  {i.  e.,  50  per  cent.)  spirit.  Iodized 
catgut  has  given  great  satisfaction  to  the  author, 

G.  G.  Macdonald  has  tested  Salkindsohn's  catgut.  His  results  are  shown 
in  the  accompanying  table: 

Yelverton  Pearson  ("  Brit.  Med.  Joum.,"  Dec.  25,  1909)  advocates  the 
use  of  "iodine-formalin"  catgut  when  u  resistant  suture  is  desired.  The  gut 
is  prepared  as  follows: 

1.  Soak  in  an  alcoholic  solution  of  iodine  (i  per  cent,  iodine,  54  per  cent. 
alcohol). 

2.  After  eight  days  remove  from  the  iodine  solution  and  wash  in  a  weak 
carbolic  solution  or  in  running  sterile  water  "to  remove  the  alcohol  and  iodine 
from  the  outer  layers  so  as  to  permit  more  freedom  for  the  action  of  the  for- 
malin." 

3.  Soak  in  3  per  cent,  formalin  solution  for  from  24  to  48  hours,  according 
to  the  thickness  of  the  gut. 

4.  Wash  in  running  water  for  a  few  hours  to  remove  the  formalin. 

5.  Place  in  50  per  cent,  alcohol  containing  1/2  per  cent,  iodine  and  5  per 
cent,  glycerine.     This  preserves  the  gut  indefinitely. 

Iodine-acetone  catgut.  McDonald's  method  ("Am.  Journ.  of  Surg.," 
May,  1 9 10): 

Sol.  I. — Iodine  4  per  cent,  in  acetone,  soak  eight  days,  drain  off  solution. 

Sol.  II. — Acetone,  soak  four  days,  drain  off  then  cover  with 

Sol.  III. — Acetone  85  per  cent.,  Columbian  spirits  10  per  cent.,  glycerine 
5  per  cent. 

Dissolve  glycerine  in  spirits  then  add  to  the  acetone.  Keep  the  gut  in  this 
indefinitely. 

(III)  Saul's  method:  Put  the  gut  (wound  on  tubes)  into  a  pot  provided 
with  a  condenser.  Cover  the  gut  with  a  solution  of  carbolic  acid  5  parts; 
90  per  cent,  alcohol  100  parts.     Boil  for  twenty  minutes.     Preserve  the  gut 

44 


690 


LIGATURES   AND    SUTURES. 


2& 

'u 

Q 

W 

>, 

0 

rt 

i- 

Q 

<u 

0\ 

W 

<1J  C  L*  :3  (D*^  ? — 


CATGUT.  691 

in  alcohol  or  in  a  solution  of  iodoform  in  alcohol  or  alcohol  and  ether.  Ex- 
periment shows  that  gut,  soaked  in  a  culture  of  anthrax  and  covered  with 
grease,  is  sterilized  by  the  above  method  after  seven  minutes  of  boiling. 

(IV)  Chromicized  catgut:  Sterilize  the  gut  by  the  Elsberg  or  Saul  method. 
Soak  for  twelve  to  twenty-four  hours  in  a  sterile  watery  solution  of  chromic  acid 
(1:10,000).  Such  gat  lasts  from  seven  to  ten  days,  according  to  its  size.  The 
strength  of  the  solution  may  be  varied  according  to  the  ideas  of  the  surgeon. 
Preserve  in  alcohol  or  in  a  solution  of  iodoform  in  alcohol  or  alcohol  and 
ether. 

(V)  Formalinized  catgut:  Sterilize  the  gut  by  the  Elsberg  or  Saul  method. 
Soak  for  twelve  hours  in  a  i  per  cent,  watery  solution  of  commercial  formalin. 
Preserve  in  alcohol,  etc.     The  durability  of  this  gut  is  about  seven  to  ten  days. 

The  usual  method  advised  for  the  preparation  of  formalinized  catgut  is 
to  soak  it  for  twelve  to  forty-eight  hours  in  a  2  per  cent,  watery  solution  of  for- 
malin, wash  in  flowing  water  for  twelve  hours,  boil  for  twenty  minutes  in  water, 
and  preserve  in  alcohol.  Boeckman,  however,  points  out  that  the  formalin 
acting  on  the  gut  makes  its  surface  waterproof,  that  the  boiling  water  does  not 
penetrate  the  gut,  and  that,  as  a  consequence,  the  inside  of  the  ligature  is  only 
exposed  to  a  dry  heat  of  212°  F.,  which  does  not  sterilize. 

The  methods  of  sterilization  here  described  have  all  been  tested  by  the 
author  and  found  satisfactory.  In  none  of  them  is  it  necessary  to  touch  the 
gut  with  the  fingers  from  the  time  the  sterilization  begins  until  it  is  being  used 
in  operating.     Any  one  of  the  methods  described  is  as  safe  as  the  others. 

Tendon. — The  tendons  of  such  animals  as  the  kangaroo,  reindeer,  and 
whale  have  been  much  used  for  sutures  and  ligatures.  Many  surgeons  prefer 
them  to  catgut.  Sterilization  may  be  effected  as  with  catgut.  The  main  ob- 
jection to  the  use  of  tendon  is  its  expense. 


CHAPTER  LXII. 
ARTERIORRHAPHY. 

The  subject  of  arterial  suture  is  old.  Hallowell  and  Lambert,  in  1759, 
closed  a  small  wound  of  the  brachial  artery  by  passing  a  pin  through  the  edges 
of  the  wound  and  winding  a  thread  round  it  as  in  the  old  hare-lip  operation. 
Though  born  so  long  ago,  arteriorrhaphy  has  only  recently  begun  to  grow,  and 
even  at  present  is,  in  many  respects,  merely  in  the  experimental  stage.  The 
subject  is  so  important,  so  many  procedures  are  being  transferred  from  the  phy- 
siological laboratory  to  the  operating-room,  and  it  so  often  happens  that  in  an 
emergency  one  wishes  knowledge  as  to  the  possibilities  and  methods  of 
arteriorrhaphy  that  the  writer  deems  it  wise  to  introduce  a  chapter  dealing  with 
it  at  this  place. 

For  success  in  arterial  suture  the  following  things  are  essential:  (i)  Perfect 
asepsis.  (2)  A  clean-cut  wound.  (3)  Absence  of  tension  on  the  sutures.  (4) 
No  rough  handling  of  the  vessel.  (5)  An  efficient  and  wow-injurious  method  of 
obtaining  temporary  hemostasis.     (6)     Good  suture  material. 

Suture  Material. — For  a  time  catgut  was  the  favorite  material  because 
when  in  site  it  became  swollen  and  so  filled  the  needle  punctures  that  hemor- 
rhage was  prevented.  The  use  of  fine  needles,  without  cutting  edges  (intestinal 
or  seamstress'  needles)  seems  to  prevent  hemorrhage  sufficiently.  To-day 
very  fine  silk  is  the  suture  of  choice,  probably  v.  Braun's  celluloid  hemp  would 
be  as  good,  but  the  familiar  Pagenstecher's  linen  is  too  rough,  theoretically  at 
least.  Carrel  finds  it  most  important  to  impregnate  the  suture  thoroughly  with 
sterile  vaseline  so  as  to  prevent  the  deposit  of  blood-clot  on  the  thread.  This 
lubrication  of  the  thread,  a  trifle  though  it  may  seem,  is  probably  the  cause  of 
the  recent  wonderful  advances  and  successes  in  experimental  arterial  surgery. 
The  needles  used  are  fine  round  needles  (intestinal,  cambric,  seamstress') 
which  may  be  straight  or  curved.  Carrel  uses  No.  15  or  16  needles.  For 
sutures  he  formerly  procured  the  finest  silk  thread  possible,  untwisted  it  and 
used  one  of  the  strands  of  which  it  was  composed,  this  delicate  strand  consti- 
tuted the  suture  after  it  had  been  impregnanted  with  sterile  vaseline.  He  now 
obtains  silk  of  suitable  fineness  from  Lyons. 

Lilienthal  uses  No.  12  needles  and  No.  000  silk.  Dorrance  uses  No.  i 
Pagenstecher  thread  on  the  tinest  needle  the  thread  will  pass  through. 

METHOD  OF  TEMPORARY  HEMOSTASIS. 

Li  a  few  cases  the  elastic  constrictor  may  be  used,  in  most  cases  its  use 
must  render  the  operation  unnecessarily  difficult  or  be  distinctly  harmful. 

692 


SUTURE    OF  ARTERIES. 


693 


An  assistant's  fingers  may  be  applied  to  the  vessel  above  and  below  site  of 
wound,  but  while  such  form  the  safest  clamps  yet  they  get  in  the  way  and  are  not 
so  practicable  as  mechanical  appliances. 

Clamps. — Clamps  the  blades  of  which  are  covered  with  rubber  tubing  are 
serviceable.  The  best-known  clamps  are:  (a)  Broad-bladed,  delicate,  eight- 
inch  Billroth  forceps  (Murphy),  (b)  Miniature 
Doyen  hysterectomy  clamps  (Dorrance)  (Fig.  778). 
(c)  Ordinary  hemostats  (Kiimmel.)  (d)  Her  rick's 
clamp  (Sweet),     (e)  Crile's  clamp  (Fig.  779). 

Tapes,  etc. — Fine  linen  strips  thrown  around 
the  vessel  and  fastened  by  forceps  instead  of  by 
a  knot  (Carrel  and  Guthrie).  Fine,  thin  tape 
fastened  by  forceps  or  serre-fins  (Lilienthal). 
Heavy  twisted  silk  used  in  the  same  manner. 

Whatever  means  of  hemostasis  is  used,  it 
must  be  used  most  gently.  The  forceps  or  tape 
must  only  exert  enough  pressure  to  control  the 
circulation  and  not  one  iota  more.  Crushing  or 
injury  to  the  intima  is  fatal  to  success. 

SUTURE  OF  ARTERIES. 

Temporarily  occlude  the  artery  about  i  inch 
above  and  below  the  wound  with  clamps  or  tapes. 
Gently  but  thoroughly  remove  all  blood  whether 
clotted  or  not;  in  doing  this  use  the  normal  salt 
solution.  Examine  the  edges  of  the  wound;  if  they  are  lacerated  or  contused 
pare  them.  For  this  purpose  Carrel  uses  fine  scissors.  Coat  the  vessel  both 
inside  and  out  with  vaseline  (Carrel).  Carefully  resect  or  remove  the  external 
sheath  of  the  vessel  from  the  neighborhood  of  the  wound.  If  any  fibres  of  this 
fibrous  tissue  tunic  get  between  the  edges  of  the  wound  and  into  contact  with 
the  blood,  a  thrombus  will  quickly  form.     The  easiest  method  of  resecting 


Fig.  778. — Dorrance  clamp. 


Fig.  779. — Crile's  clamp. 

the  outer  coat  is  to  pull  it  forwards  over  the  inner  coat  and  clip  it  off  with 
scissors  (Fig.  780). 

Methods  of  Suture. — Interrupted  or  continuous  sutures  may  be  chosen  at 
the  option  of  the  operator;  the  continuous  suture  is  the  favorite. 

Method  A. — Pass  the  suture  as  in  Fig.  781  without  damaging  the  intima. 
This  is  possible  in  large  arteries,  but  impossible  in  medium-sized  ones  or  in 


694 


ARTERIORRHAPHY. 


veins.  The  disadvantages  of  the  method  are  the  limitations  of  its  applicability; 
its  difficulty;  the  possibility  of  fibrin  ferment  passing  from  the  arterial  walls 
to  the  blood-stream;  the  possible  presence  of  fringes  of  intima  hanging  into  the 
blood-stream  and  favoring  coagulation  and  the  possibility  of  blood  passing 
through  the  open  intima,  infiltrating  the  vessel-wall,  thus  causing  aneurysm. 

Method   B.     Through -and -Through   Sutures. — Close    the    wound   by 
sutures  penetrating  all  the  coats  of    the  vessel,  taking  care  "not  to  include 


Line  of  seef/o// 

Adve/ititia. 


Fig.  780. 


Fig.  781. 


fragments  of  the  connective-tissue  layer  in  the  line  of  suturing,  and  to  obtain 
a  smooth  union  and  approximation  of  the  endothelial  coats"  (Carrel). 

Figs.  782  and  783  are  self-explanatory.  During  the  passage  of  the  sutures 
the  extreme  edges  of  the  wound  may  be  held  in  delicate  dissecting  forceps.  A 
thimble  is  useful  in  pushing  the  needle  through  the  tissues.  This  method  has 
given  many  excellent  results.  The  line  of  union  may  be  strengthened  by 
separate  suture  of  the  adventitia. 

Method  C.  Brieau-Jaboulay  Suture. — This  suture  is  highly  commended 
by  Archibald  Smith,  and  a  practically  identical  stitch  has 
been  advised  by  Dorrance. 

The  suture  produces  eversion  of  the  lips  of  the  wound 
and  brings  intima  into  contact  with  intima.  Prima  jade 
one  would  think  such  a  suture  would  produce  stenosis, 
but  A.  Smith's  researches  show  that  such  is  not  the  case. 

Pass  a  stitch  from  without  inwards  through  all  the  coats 
of  the  wounded  vessel  at  the  point  a  (Fig.  784);  pass  the 
same  thread  from  within  outwards  through  all  the  coats 
of  the  opposite  side  of  the  wound  at  the  corresponding 
point  b.  Reintroduce  the  stitch  from  without  inwards 
at  c,  and  complete  its  course  by  bringing  it  from  within  outwards  through  the 
whole  thickness  of  the  vessel-wall  at  d.  This  leaves  in  place  a  U-suture  which 
everts  the  lips  of  the  wound.  In  a  short  wound  or  puncture  one  U-suture  may 
suffice;  in  a  longer  wound  several  will  be  necessary,  each  tied  separately  or 
placed  in  a  continuous  fashion. 

Method  D.  Brewer's  Adhesive  Plaster. — George  Brewer,  having  had 
ill  results  from  arterial  sutures  failing  to  hold,  has  wrapped  wounded  vessels 
with  an  "elastic  plaster  made  up  of  a  strip  of  very  thin  gum  (rubber),  coated 
with  an  adhesive  material  like  that  used  in  the  zinc  oxide  plaster.  Experiments 
were  made  on  a  large  number  of  animals  and  some  of  the  results  were  good." 


Fig.  782. 


ANASTOMOSIS. 


695 


The  method  does  not  seem  to  have  been  used  in  practice.  The  objections  to 
the  method  are:  Difhcuky  in  applying  the  plaster  with  sufficient  and  not  too 
much  tension;  the  almost  certain  absence  of  the  material  when  it  is  required;  a 
foreign  body  being  left  in  the  wound. 


Fig.  783. 

END-TO-END  ARTERIAL  ANASTOMOSIS. 

Circular  arteriorrhaphy  is  of  value  when  an  artery  of  size  has  been 
completely  divided  or  a  portion  of  it  has  been  excised.  The  same  general  rules 
laid  down  for  suture  of  arterial  wounds  apply  to  the  operation  about  to  be  de- 
scribed. 

Sweet  prepares  the  divided  ends  of  the  vessel  for  suture  by  carefully  removing 
the  loose  connective-tissue  sheath  (adventitia)  about  the  ends  of  the  vessel 
(Fig.  780).  "This  can  be  done  very  nicely  by  grasping  the  sheath  with 
forceps,  drawing  it  over  the  end  of  the  vessel  and  clipping  it  off  with  scissors." 


"■^i5^5^^^^^^^f^^?C^fww?iS\T 


' I'll  H /I 'it;' 


"iiiiuinuipj/tj, 


/  /  nil 

Fig.  784. 


Fig.  785. 


Fig.  786. 


During  the  operation  keep  the  vessels  from  drying  either  by  moistening  with  salt 
solution  or  by  applying  sterile  vaseline.  When  the  suture  is  complete  and  the 
blood  allowed  to  resume  its  circulation  there  is  rarely  any  bleeding,  and  such 
as  there  is  is  easily  controlled  by  temporary  pressure. 

Payr's  Method.  Magnesium  Prosthesis. — Have  at  hand  a  number  of  rings 
grooved  on  their  outer  surface,  of  dififerent  sizes  and  made  of  very  thin  mag- 
nesium. 

Step  I. — To  the  cut  edges  of  the  central  segment  of  artery  apply  four  line 
silk  sutures  penetrating  all  the  coats  of  the  vessel  (Fig.  785). 


696 


ARTERIORRHAPHY. 


Step  2. — Choose  a  ring  which  will  fit  accurately  round  the  artery.  Pass 
the  four  threads  through  the  ring  (Fig.  785).  With  the  threads  pull  the  artery 
through  the  ring  until  an  amount  of  artery  protrudes  form  the  ring  rather 
greater  than  the  width  of  the  ring  (Fig.  786). 

Step  3. — Aided  by  the  threads,  turn  the  protruding  cuff  of  artery  backwards 
over  the  ring  and  fix  it  in  place  by  tying  a  fine  ligature  round  it  (Fig.  787).  The 
groove  in  the  ring  prevents  the  ligature  from  slipping. 

Step  4. — Introduce  four  sutures  into  the  cut  edge  of  the  peripheral  segment 
(Fig.  788). 


'\\V«  >  tVv 


Fig.  787. 


Step  5. — Make  traction  on  these  four  threads  and  so  distend  the  lumen  of 
the  peripheral  segment  (Fig.  787).  Push  the  central  segment  (with  its  rings) 
into  the  distended  peripheral  segment.  When  the  peripheral  segment  covers 
the  ring,  fix  it  in  place  with  a  ligature  (Fig.  789). 

This  completes  the  operation.  It  will  be  seen  that  the  ring,  though  buried,  is 
extra-vascular.  Magnesium  is  dissolved  and  absorbed  in  the  body,  hence  no 
persistent  foreign  substance  is  left  in  the  wound.  (Payr,  "Archiv  fiir  klin. 
Chir,"  Ixii,  i;  Ixiv,  3;  Ixxii,  i.) 

Murphy's  Method. — Invagination. — Step.  i. — Introduce  a  fine  cambric 
needle  armed  with  fine  silk,  through  all  the  tunics  of  the  distal  segment  of  the 


''\\i\4\VS!^\ 


Fig.  789. 


Fig.  790. 


Fig,  791. 


vessel  from  without  inwards  at  the  point  A  about  1/3  inch  distant  from  the  di- 
vided edge  of  the  vessel  (Fig.  790).  Bring  the  needle  out  through  the  open  end 
of  the  vessel.  With  the  needle  pick  up  a  small  portion  of  the  adventitia  and 
media  (not  the  intima)  at  the  point  C,  near  the  cut  edge  of  the  proximal  segment 
of  vessel.  Introduce  the  same  needle  through  open  lumen  of  the  peripheral 
segment  and  make  it  penetrate,  from  within  outwards,  the  whole  thickness  of 
the  vessel  at  a  point  close  to  A.     The  result  of  this  is  a  U  or  mattress  suture. 


SUTURE    OF   ARTERIES. 


697 


Introduce  two  other  sutures  in  the  same  manner  so  that  three  U-stitches  are  in 
position  at  equal  distances  from  each  other. 

Step  2. — Pull  on  the  three  U-sutures  and  so  invaginate  the  proximal  into  the 
distal  segment  of  vessel  (Fig.  791).  Tie  the  sutures.  Before  invaginating  it 
may  be  necessary  to  make  a  slight  longitudinal  split  (x)  in  the  receiving  or  distal 
segment. 

Step  3. — With  fine  sutures  unite  the  edge  of  the  distal  to  the  side  of  the  proxi- 
mal segment  at  the  line  where  the  former  overlaps  the  latter.  If  a  longitudinal 
split  has  been  made,  close  it  also  with  a  stitch. 


Fig.   792. —  {Dorrance.) 


Fig.  793. — {Dorrance.) 


Step  4. — Carefully  suture  any  available  tissues  near  the  vessel  in  such 
fashion  as  to  give  the  maximum  of  support  to  it. 

Eversion  Method.  Brieau  and  Jaboulay's  Sutures  Modified  by  Dor- 
rance.— "The  clamps  are  applied  as  before.*  The  cut  edges  of  the  artery  are 
grasped  with  dissecting  forceps,  and  the  suture  is  passed  through  the  upper 
edge  of  the  artery  from  without  in  and  through  the  lower  end  from  within  out; 
the  needle  is  then  reversed  and  brought  back  1.5  mm.  to  one  side  of  the  former 
suture  and  tied.  (This  suture  is  really  a  single  mattress  suture.)  The  suture 
is  continued  as  a  continuous  mattress  suture,  dropping  b*ack  half  a  stitch  every 
third  suture  until  the  starting-point  is  reached,  then  a  half  stitch  is  made  and 

*  The  clamps  used  by  Dorrance  are  miniature  copies  of  Doyen's  hysterectomy  clamp 
(Fig.  778). 


698 


ARTERIORRHAPHY 


the  suture  continued  back  as  a  whip-stitch  until  the  starting-point  is  reached 
again;  then  the  two  ends  are  tied  (Figs.  792  and  793).  The  suture  is  started  on 
the  anterior  surface  near  the  handles  of  the  clamps.  When  the  suture  reaches 
the  farther  side  of  the  artery  the  handles  of  the  clamps  are  taken  from  the 
lower  portion  of  the  wound  and  placed  in  the  upper  portion.  In  this  way  the 
surface  of  the  artery  which  was  anterior  is  now  posterior,  and  the  suture  can 
always  be  kept  in  sight." 

Carrel's  Method.— Step  i. — Introduce  three  tension  sutures  of  very  fine 
silk  impregnated  with  vaseline,  at  equidistant  points  of  the  circumference  of 


Fig.  794. — (Carrel.) 


the  vessel  ends  (Fig.  794)-*     These  sutures  penetrate  the  whole  thickness  of  the 
vessel-walls. 

Step  2. — Have  an  assistant  apply  traction  to  two  of  these  sutures  so  as  to 
stretch  the  portion  between  the  two  sutures  into  a  straight  line  and  to  approxi- 
mate the  corresponding  cut  edges  of  the  vessel.  Apply  a  hemostat  to  the 
third  tension  suture  and  let  it  hang  so  as  to  pull  on  the  suture.  The  slight  pull- 
ing on  the  three  sutures  arranges  the  circumference  of  the  vessel  as  a  triangle, 
and  this  facilitates  suturing. 

Step  3. — Introduce  a  continuous  overhand  stitch  through  all  the  coats  all 
round  the  vessel.  Tlfe  stitches  should  be  very  close  together  and  only  drawn 
tightly  enough  to  secure  approximation,  but  not  tightly  enough  to  produce 
eversion  of  the  edges  of  the  wound  (Fig.  795). 

*  In  the  illustration  four  tension  sutures  have  been  employed. 


VENOUS    IMPLANTATION. 


699 


Step  4. — Remove  the  distal  clamp  (used  for  provisional  hemostasis).  Re- 
move the  proximal  clamp.  If  there  is  any  bleeding,  gentle  finger  pressure  will 
almost  always  stop  it  (Fig.  796).  If  necessary  for  hemostasis,  introduce  one  or 
two  interrupted  sutures. 

Step  5. — Close  the  wound  after  putting  one  or  two  stitches  in  the  adventitia 
to  reinforce  the  main  arterial  suture. 


Fig.    795. — (Carrel.) 

VENOUS  IMPLANTATION. 

WTien  the  severed  ends  of  the  artery  are  so  distant  that  approximation  is 
impossible  one  may  bridge  the  defect  by  implanting  a  segment  of  vein.  E. 
Lexer  ("  Archiv  flir  klin.  Chir.,"  Ixxxiii,  459)  reports  a  case  of  axillary  aneurysm 
which  he  excised;  approximation  of  the  ends  of  the  artery  being  impossible,  he 
excised  a  branchless  segment  of  the  great  saphenous  vein,  united  its  distal  end 


Fig.  796. — (Carrel.) 

to  the  proximal  segment  of  artery  and  its  proximal  end  to  the  distal  portion  of 
artery.  The  union  was  effected  after  Carrel's  method.  There  was  no  hemor- 
rhage and  no  thrombosis  at  the  line  of  suture.  The  segment  of  vein  seemed 
to  act  well.  Experiments  have  shown  that  veins  when  substituted  for  arteries 
become  thickened,  stronger,  and  adapt  themselves  to  their  new  duties. 

Some  of  Carrel's  experiments  on  dogs  and  cats  show  admirably  the  possi- 
bilities of  operations  on  the  vascular  system.     At  the  Rockefeller  Institute, 


70O  ARTERIORRHAPHY. 

New  York,  Carrel  exhibited  to  the  members  of  the  Society  of  Clinical  Surgery 
healthy-looking  animals  on  which  the  following  operations  had  been  performed: 
(a)  Excision  of  segment  of  abdominal  aorta,  a  corresponding  segment  of  vena 
cava  being  inserted  to  take  its  place,  (b)  Excision  of  segment  of  abdominal 
aorta,  a  corresponding  segment  of  an  aorta  which  had  been  kept  in  cold  storage 
for  some  days  being  implanted  into  the  gap.  (c)  Double  nephrectomy — both 
kidneys  being  replanted.  On  suture  of  the  vessels  and  ureters  secretion  of 
urine  quickly  manifested  itself,  (d)  Amputation  of  the  thigh  of  a  black  dog — 
implantation  of  the  corresponding  amputated  thigh  of  a  white  dog  on  to  the 
stump.  When  exhibited  healing  was  not  complete,  but  circulation  was  estab- 
lished in  the  implanted  thigh. 

Some  of  the  operations  described  in  the  preceding  paragraphs  almost 
appear  as  if  they  were  the  offspring  of  a  superheated  imagination,  but  many  of 
them  have  been  applied  in  surgery  with  most  conservative  and  gratifying  results. 
It  may  be  well  and  encouraging  to  briefly  note  a  few  cases  in  which  the  methods 
devised  after  animal  experimentation  have  been  applied  to  man. 

Frank  T.  Stewart  ("Annals  of  Surg.,"  July,  1908)  reports  two  cases  of  re- 
section of  the  brachial  artery,  one  by  the  Murphy  method  with  probable  throm- 
bosis, the  other  by  Carrel's  method  with  success. 

Kummel,  during  an  operation  for  malignant  disease,  excised  about  i  3/4 
inches  of  the  femoral  artery.  He  successfully  repaired  the  vessel  by  invaginat- 
ing  the  central  into  the  peripheral  end. 

E.  Martin  ("Med.  Klinik.,"  1908,  No.  38)  performed  circular  arteriorrhaphy 
(Carrel's  method)  after  resection  of  i  1/4  inches  of  the  brachial  artery  injured 
by  a  trauma  near  the  elbow.  After  union  a  slight  murmur  was  audible  over 
the  scar. 

Braun  ("Archiv  flir  klin.  Chir.,"  Ixxxvi,  707),  while  removing  a  retroper- 
itoneal tumor  made  an  oblique  tear  in  the  aorta.  The  tear  involved  about  half 
the  circumference  of  the  vessel,  the  walls  of  which  had  been  thinned  from  pres- 
sure by  the  tumor.  In  anticipation  of  injuring  the  aorta  the  vessel  had  been 
provisionally  compressed.  Suture  of  the  wound  by  a  single  layer  of  stitches  was 
insufficient  to  prevent  bleeding,  and  a  second  row  when  introduced  produced 
too  much  stenosis  (absence  of  femoral  pulse,  coldness  of  limbs),  so  Braun  excised 
the  injured  segment  of  aorta  and  united  the  cut  ends  by  Carrel's  method,  A 
small  iodoform  gauze  tampon  was  placed  against  the  line  of  suture  and  the 
abdominal  wound  closed  around  the  tampon.  The  tampon  was*  removed  on 
the  eighth  day.  The  patient  was  confined  to  bed  for  four  weeks.  Three  months 
later  the  patient  was  well. 

TREATMENT  OF  THROMBOSIS  AND  EMBOLISM  BY  OPERA- 
TIONS ON  THE  VESSELS. 

It  is  necessary  to  distinguish  between  closure  of  an  artery  by  a  clot  forming 
on  an  injured  or  diseased  intima  and  closure  due  to  an  embolus  lodging  in  a 
more  or  less  healthy  artery.     In  the  first  case  removal  of  the  blood-clot  alone  is 


THROMBOSIS.  70I 

valueless,  as  another  clot  will  form  immediately.  If  the  injured  or  diseased 
portion  of  vessel  is  of  a  very  hmited  extent  that  portion  may  be  excised  and  the 
divided  ends  of  the  vessel  united  by  arteriorrhaphy  or  by  the  implantation  of  a 
segment  of  vein.  If  venous  implantation  is  attempted  do  not  use  the  compan- 
ion vein  to  supply  the  defect,  this  would  be  calculated  to  seriously  interfere 
with  the  return  circulation.  Probably  in  thrombosis  it  may  be  better  to  send 
blood  down  into  the  limb  through  a  vein  (reversal  of  circulation),  as  will  be 
described  later.  When  the  closure  of  the  artery  is  due  to  the  lodgment  of  an 
embolus,  it  is  logical  to  open  the  vessel  by  a  longitudinal  incision  after  providing 
for  temporary  hemostasis,  extract  the  clot,  wash  the  interior  of  the  segment  of 
vessel  segregated  by  the  hemostatic  tapes  or  clips,  with  salt  solution,  smear  it 
with  sterile  vasehne  and  close  the  wound  with  sutures.  P'rank  Stewart  reports 
an  unsuccessful  case  of  such  an  operation  ("Annals  of  Surg.,"  Sept.,  1907). 
To  be  successful  it  is  necessary  that  the  diagnosis  of  obstruction  by  embolism 
be  made  early  and  operation  be  promptly  carried  out.  Of  course  the  procedures 
mentioned  are  not  at  all  estabUshed,  but  it  is  necessary  for  operating  surgeons  to 
bear  them  in  mind.  Instead  of  attacking  arterial  obstruction  directly  the  sur- 
geon may  to  some  extent  reverse  the  circulation  in  the  limb  and  so  dodge  the 
impediment. 

J.  C.  Hubbard  ("Annals  Surg.,"  Oct.,  1906,  and  Sept.,  1907),  in  a  case  of 
gangrene  of  the  foot,  isolated  the  femoral  artery  and  vein  at  the  apex  of  Scarpa's 
triangle  below  the  origin  of  the  profunda  and  divided  them  after  providing  for 
temporar}^  hemostasis.  He  invaginated  the  upper  end  of  the  artery  into  the 
lower  end  of  the  vein  as  in  Murphy's  method  of  arteriorrhaphy.  After  the  opera- 
tion there  was  no  oedema,  dilatation  of  the  veins,  or  cyanosis.  The  gangrene 
present  before  operation  spread  a  Httle  and  then  a  line  of  demarcation  formed. 
When  the  foot  was  later  amputated  at  the  point  of  election  on  the  tibia,  both 
tibial  arteries  contained  arterial  blood.  The  stump  healed  satisfactorily  but 
slowly.  Hubbard  writes:  "It  seems  that  the  arterio-venous  anastomosis  must 
have  increased  in  some  way  the  amount  of  blood  in  the  leg,  for  it  is  hard  to 
believe  that  an  amount  of  blood  so  small  as  to  permit  gangrene  of  the  foot  would 
be  sufficient  to  nourish  for  ten  months  an  amputation  stump  made  only  a  short 
distance  above  the  gangrenous  area  and  had  thrombi  formed  at  the  sites  of  the 
anastomosis;  it  seems  most  probable  that  the  gangrene  would  have  extended 
up  the  leg  instead  of  remaining  localized." 

Doberauer  reports  a  case  of  embolism  of  the  right  axillary  artery.  The 
trouble  had  lasted  fifty-two  hours,  and  there  was  already  present  a  commencing 
gangrene  and  ischaemic  contracture  of  the  limb. 

Doberauer  performed  arteriotomy,  removed  a  clot  about  3  cm.  in  length  and 
sutured  the  artery.  A  new  clot  formed  in  a  few  hours  and  was  removed  in 
the  same  manner.  Once  more  the  thrombus  reformed  and  after  two  days  the 
gangrene  notably  progressed. 

Arterio-venous  anastomosis  was  now  made  between  the  axillary  artery  and 
vein.     As  soon  as  the  anastomosis  was  completed  and  the  blood  current  per- 


702 


ARTERIORRHAPHY. 


mitted  to  flow,  "one  perceived  the  eruption  of  the  arterial  blood  into  the  vein  in 
the  form  of  a  little  explosion  and  one  saw  the  blood  advance  to  the  level  of  the 
wrist."  The  vein  pulsated  like  an  artery.  Twelve  days  after  operation  the 
circulation  remained  good. 

In  a  patient  who  had  lost  his  left  leg  from  gangrene  due  to  arterial  sclerosis, 
marked  symptoms  of  the  same  affection  appeared  in  the  remaining  lower  limb. 
Wieting  Pasha  exposed  the  femoral  artery  and  vein  at  the  apex  of  Scarpa's  tri- 
angle, divided  the  artery  completely  and  introduced  its  central  portion  into  the 


Fig.  797. 


Fig.  798. 
.1  A.  Cut  edge  of  vein. 


femoral  vein  for  a  distance  of  at  least  3/8  inch  (i  cm.)  through  an  incision  made 
on  the  anterior  surface  of  the  vein.  The  union  was  effected  by  sutures  which 
penetrated  the  whole  thickness  of  the  wall  of  the  vein  but  only  the  outer  coats  of 
the  artery.  The  vein  was  ligated  above  the  point  of  anastomosis.  The  foot 
soon  became  warm  and  rosy.  Two  months  after  the  operation  the  circulation 
remained  satisfactory  ("Deutsche  med.  Woch.,"  1908,  No.  28). 

In  October,  1908,  J.  B.  Murphy  exhibited  to  the  Society  of  Clinical  Surgery 
a  patient  in  whom  he  had  successfully  established  arterial  circulation  through  the 

Cuff  of  vein  fun/ed 
QacA  oi'cr  forceps. 


Fig.  799. 
B  B.  Sutures  through  cut  edge  of 
artery  and  folded  edge  of  vein. 


Fig.  800. 


He  operated  as 
(Divide 


femoral  vein    for  gangrene  of   the  foot  due  to  endarteritis, 
follows: 

(i)  Exposure  of  the  femoral  artery  and  vein  and  division  of  both 
the  vein  at  a  slightly  higher  level  than  the  artery) . 

(2)  Apply  forceps  (Fig.  797)  around  the  distal  segment  of  the  vein  near  its  end 
(A,  Fig.  798).     Pull  the  open  end  of  the  vein  back  over  the  forceps  (Fig.  799). 

(3)  Suture  the  open  end  of  the  proximal  segment  of  the  divided  artery  to  the 
inside  of  the  vein  where  it  is  reflected  over  the  forceps  (B,  Fig.  799). 


THROMBOSIS.  703 

(4)  Pull  the  reflected  portion  of  vein  over  the  line  of  suture  (Fig.  800)  and 
suture  its  cut  end  to  the  surface  of  the  artery. 

(5)  Remove  the  forceps. 

In  speaking  of  the  operation  Murphy  said  that  it  would  have  been  better  to 
have  made  a  lateral  anastomosis  between  the  artery  and  vein  and  then  to  have 
tied  the  vein  proximal  to  the  site  of  anastomosis;  by  so  doing  it  would  have 
been  possible  to  continue  sending  blood  down  the  stenosed  artery  while  arterial 
blood  passing  down  the  vein  would  supply  the  deficiency  created  by  the  nar- 
rowing of  the  artery. 

Monod  finds  that  only  6  out  of  27  cases  of  arterio-venous  anastomosis  for 
gangrene  have  given  satisfactory  results  in  that  the  blood  has  flowed  to  the  ex- 
tremity of  the  member  and  that  the  limb  has  recovered  as  shown  by  the  healing 
of  trophic  lesions.  In  these  6  cases  there  was  none  confirmed,  only  threatened 
gangrene.  None  of  these  cases  have  been  followed  long  enough  so  that  definite 
conclusions  can  be  reached. 


CHAPTER  LXIII. 

ANEURYSM. 

A  short  discussion  of  the  forms  and  varieties  of  aneurysm  may  be  of  benefit 
as  clarifying  the  consideration  of  their  treatment.  While  trauma  is  an  impor- 
tant cause  of  aneurysm,  e.  g.,  gun-shot  wound  causing  arterio- venous  aneurysm, 
yet  a  weakening  of  the  arterial  wall  from  disease  is  by  far  the  most  common 
cause  of  the  trouble. 

(A)  When  an  artery  ruptures,  whether  from  trauma,  disease,  or  both, 
l)leeding  into  the  surrounding  tissues  takes  place  resulting  in  a  hematoma.  If 
the  wound  in  the  vessel  heals  there  may  be  no  further  trouble;  if  the  wound 
does  not  heal  and  if  from  pressure,  etc.,  the  tissues  surrounding  the  effused 
blood  become  condensed  so  as  to  form  a  capsule,  then  a  pulsating,  well-defined 
tumor  is  formed,  the  cavity  of  which  communicates  directly  with  the  lumen  of 
the  wounded  artery.     This  pulsating  tumor  is  known  as  a  false  aneurysm. 

(B)  When  an  artery  and  a  vein  lying  alongside  each  other  are  simultane- 
ously wounded  and  the  wound  is  treated  by  compression,  the  two  vessels  may 
adhere,  the  superficial  wound  may  heal,  the  openings  into  the  vessels  may  not 
close,  but  may  form  an  arterio-venous  anastomosis,  the  arterial  blood  passing 
directly  into  the  vein.  This  condition  is  known  as  an  aneurysmal  varix  and  may 
or  may  not  occasion  any  trouble.  Instead  of  adhering  one  to  the  other,  the 
artery  and  vein  may  each  bleed  into  the  surrounding  tissues  and  give  rise  to  a 
false  aneurysm  which  communicates  directly  with  the  lumen  of  each  vessel,  so 
that  the  arterial  blood  passes  from  the  artery  to  the  vein  through  the  intermediate 
sac.  This  condition  is  known  as  a  varicose  aneurysm  and  is  of  more  moment 
than  aneurysmal  varix.  The  two  varieties,  viz.,  varicose  aneurysm  and  aneu- 
rysmal varix  have  the  common  name  anterio-venous  aneurysm. 

(C)  Cirsoid  aneurysm  is  a  condition  in  which  a  number  of  dilated  arteries, 
held  together  by  connective  tissue,  form  a  tumor  which  is  the  arterial  equivalent 
of  the  venous  varicocele.  The  disease  is  most  common  in  the  scalp,  and  its 
treatment  is  very  similar  to  that  of  angioma. 

(D)  True  Aneurysm. 

1.  When  disease  {e.  g.,  atheroma)  weakens  the  whole  circumference  of  an 
artery,  dilatation  is  liable  to  take  place  (Fig.  8oi,  8,  9,  10).  The  whole  circum- 
ference being  affected,  the  dilatation  is  uniformly  fusiform  except  in  so  far  as 
it  is  affected  by  surrounding  supporting  structures  (Fig.  801,  11,  12,  13).  This 
is  a.  fusiform  aneurysm. 

2.  When  disease  weakens  a  limited  portion  of  the  circumference  of  an  artery, 
a  pouching  of  the  arterial  wall  outwards  is  liable  to  take  place,  just  as  a  bulging 

704 


ANEURYSM. 


705 


or  pouting  of  a  pneumatic  tire  forms  when  a  li.mted  portion  of  the  tire  has  be- 
come weakened  (Fig.  801,  i,  2,  3,  4,  5,  6,  7).  In  this  manner  a  larger  or  smaller 
sac  is  formed  communicating  with  the  lumen  through  a  more  or  less  circular 
opening  or  through  a  longitudinal     cleft  in  the  vessel-wall.     This  variety  is 


UO" 


known  as  a  sacculated  aneurysm  (Fig.  801,  3).  If  the  sac  of  such  an  aneurysm 
is  opened,  only  one  orifice  may  be  seen  leading  into  the  artery;  if  two  orfices 
are  visible,  they  are  connected  by  a  groove  in  the  wall  of  the  sac  leading  from 
one  orifice  to  the  other  (Fig.  801,  7).  This  groove  consists  of  normal  artery  wall 
45 


7o6  ANEURYSM. 

and  in  fact  is  the  artery  which  communicates  with  the  sac  through  a  split  of 
limited  width  instead  of  through  an  opening  of  limited  length  and  width  (Fig. 
8oi,  14).  A  recognition  of  these  facts  is  very  important,  as  such  aneurysms  may 
be  suitable  for  reconstructive  operations,  while  fusiform  aneurysms  with  which 
they  are  often  confounded  are  entirely  unsuited  to  such  treatment. 

(E)  A  true  aneurysm  may  rupture  and  form  a  false  aneurysm  in  addition. 
This  must  be  remembered  as  the  condition  may  puzzle  an  operator  when  per- 
forming endo-aneurysmorrhaphy. 

LIGATION. 

(a)  Operation  of  Antyllus.— Expose  the  aneurysm  along  with  the  artery 
immediately  above  and  below  it  (Fig.  802).  Ligate  the  artery  immediately 
above  and  below  the  aneurysm.  Open  the  sac;  turn  out  contained  blood-clots; 
excise  as  much  of  the  sac  as  convenient;  close  the  wound.  This  operation  is 
rarely  performed  except  in  very  superficial  vessels.  Other  and  better  methods 
are  available,  but  the  procedure  is  worthy  of  note  as  being  the  earliest  form  of 
operation  and  being  very  closely  allied  to  some  of  the  most  modern. 

(b)  Ariel's  Operation. — Expose  the  artery  proximal  to  the  aneurysm. 
Ligate  close  to  the  aneurysm,  so  close,  in  fact,  that  no  branch  is  given  off  from 


Fig.  802.  Fig.  803. 

the  artery  between  the  ligature  and  the  sac.  The  objections  to  this  operation 
are  that  the  ligature  is  applied  on  more  or  less  diseased  tissue  (not  a  very  grave 
fault  in  view  of  the  success  of  Matas'  operation)  and  that  blood  may  soon  enter 
the  sac  through  collateral  circulation  (Fig.  803). 

(c)  Hunter's  Operation. — To  avoid  ligating  diseased  tissue  John  Hunter 
operated  at  a  distance  from  the  aneurysm.  In  popliteal  aneurysm  he  ligated  the 
femoral  in  Hunter's  canal;  later  surgeons  preferred  to  ligate  at  the  apex  of 
Scarpa's  triangle.  Collateral  circulation  does  not  pour  blood  into  the  sac  so 
early  as  after  Anel's  operaton  (Fig.  804). 

(d)  Brasdor's  Operation. — When  an  aneurysm  is  so  near  the  trunk  that 
proximal  ligation  is  impracticable,  distal  ligation  may  form  a  barrier  to  the  on- 
flow of  blood,  collateral  circulation  may  be  established,  and  a  cure  result. 

Brasdor's  operation  consists  in  ligating  the  main  artery  distal  to  the  aneu- 
rysm (Fig.  805). 

(e)  Wardrop's  Operation. — When,  for  example,  in  innominate  aneurysm, 


ANEURYSM. 


707 


the  artery  divides  into  two  great  vessels,  the  circulation  may  be  sufficiently 
checked  by  the  ligation  of  one  of  these  vessels  distal  to  the  disease  (Fig.  806) . 
This  is  Wardrop's  operation.  If  ligation  of  the  one  vessel  prove  insufficient,  the 
other  branch  may  be  tied  as  well  so  that  the  same  condition  prevails  as  in  Bras- 
dor's  operation. 

(f)  Syme's  Operation  is  practically  obsolete.  It  consisted  in  incising 
the  aneurysm  freely,  quickly  inserting  the  finger  so  as  to  plug  the  afferent  vessel 
and  then  in  catching  with  a  forceps,  through  the  cavity  of  the  sac,  the  mouth 
of  the  vessel,  and  subsequently  obliterating  it  with  a  ligature  or  stitch. 

(g)  Dix's  Operation.— ("Brit.  Med.  Jour.,"  Oct.  30,  1875,  and  "Bryant's 
Surg., "3d  ed.,  1,449.)  Gradual  constriction  of  the  afferent  artery.  This  method 
has  been  much  neglected,  and  yet  it  has  many  valuable  features.  It  imitates 
nature's  cure  by  gradually  decreasing  and  then  stopping  the  onflow  of  blood. 
If  coldness  of  the  limb  indicates  that  the  circulation  has  been  interfered  with  too 


Fig.  804. 


Fig.  805. 


Fig.  806. 


much,  the  constriction  may  be  loosened  slightly  and  an  opportunity  given  for  a 
sufficient  estabishment  of  collateral  circulation.  Stratton,  Halstead  and  Matas 
have  used  this  same  principle  in  various  ways. 

Expose  the  artery,  encircle  it  with  a  strand  of  soft  silver  wire  about  nine 
inches  long.  With  a  needle  pass  the  ends  of  the  wire,  from  within  outwards, 
through  the  tissues  to  the  surface  so  as  to  emerge  on  the  skin,  one  about  a  quar- 
ter of  an  inch  and  the  other  three-quarters  of  an  inch  from  the  edge  of  the 
wound,  both  being  on  the  same  side  of  the  wound.  Divide  a  small  cork  longitudi- 
nally; place  one-half  of  this  between  the  emerging  ends  of  wire,  flat  surface  to 
skin,  with  its  long  axis  exactly  in  the  line  of  the  artery^  and  press  down  upon  it; 
twist  the  ends  of  the  wire  over  the  cork  until  pulsation  ceases  in  the  aneurysm. 
Close  the  skin  wound.  "When  depression  of  anaethesia  goes  off  and  the  circu- 
lation revives,  it  will  be  found  that  a  feeble  pulsation  returns  in  the  aneurysm. 
This,  according  to  the  author  (who  strongly  advocates  the  gradual  rather  than 
the  rapid  method  of  producing  coagulation  in  the  sac),  should  be  allowed  to  go 
on  for  two  or  even  three  days,  when  the  wire  is  to  be  tightened"  (Thomas 
Bryant.)  To  tighten  the  wire,  press  down  on  the  cork  and  slip  small  wedges 
of  wood  (matches  would  do)  between  the  wire  and  the  cork.     Do  not  twist  the 


7o8  ANEURYSM. 

wire  afresh  lest  it  break.     "About  the  fifth  or  sixth  day  the  cure  is  complete" 
and  the  wire  may  be  removed. 

EXCISION  OF  ANEURYSM. 

Adolf  Treutlein  ("Miinch.  med.  Woch.,"  June  19,  1906)  recommends 
that  in  traumatic  aneurysm  finger  pressure  be  used  to  the  affected  part  two  or 
three  times  daily  for  fifteen  minutes  during  a  period  of  about  two  weeks  prior  to 
operation.  The  object  of  this  preliminary  treatment  is  to  encourage  the  develop- 
ment of  collateral  circulation  and  lessen  the  dangers  of  gangrene.  Ellsworth 
Eliot,  Jr.,  has  preached  this  doctrine  for  years.  Freely  expose  the  aneurysm  by 
incision.  Ligate  the  artery  proximal  to  the  sac.  If  practicable  ligate  the 
artery  distal  to  the  sac.  Remember  that  branches  may  be  given  off  from  the 
sac  and  that  these  may  bleed.  Excise  the  sac  as  if  it  were  a  wow-malignant 
tumor.  It  may  be  easy  to  remove  the  aneurysm  without  opening  it,  it  will 
generally  be  much  easier  if  the  sac  is  opened  and  its  contents  evacuated  not 
merely  because  of  increased  ease  in  manipulation,  but  because  the  openings  of 
the  branch  vessels  may  be  visible  and  thus  their  exposure  and  ligation  be  facili- 
tated. In  old  aneurysms  with  their  numerous  irregularities  and  adhesions 
extirpation  may  be  very  difficult.  When  the  wall  of  the  sac  is  closely 
adherent  to  important  structures  rather  leave  a  portion  of  the  sac  in  situ  than 
jeopardize  such. 

If  temporary  hemostasis  has  been  obtained  by  an  elastic  constrictor,  hemor- 
rhage is  likely  to  be  so  considerable  on  its  removal  that  Hildebrand  gives  the 
following  advice:  Tampon  the  wound  and  elevate  the  limb  before  removing  the 
constrictor.  Remove  the  constrictor.  After  about  10  to  15  minutes  the  tem- 
porary hyperemia  always  noticeable  after  removal  of  a  constrictor  will  have 
disappeared,  and  it  becomes  easy  to  pick  up  and  tie  all  bleeding  points. 

The  development  of  arteriorrhaphy  renders  it  possible  to  substitute  a  more 
ideal  operation  for  the  classical  method  of  excision  of  an  aneurysm.  Instead  of 
ligating  the  artery  above  and  below  the  aneurysm,  it  is  temporarily  occluded 
by  means  of  Crile's  clamps  or  the  like  (unless  Esmarch's  elastic  constrictor 
has  been  used) ;  the  aneurysm  is  excised  and  the  afferent  and  efferent  segments 
of  the  artery  are  united  by  suture. 

Enderlen  (Wiirzburg)  ("Deutsche  med.  Woch.,"  1908,  No.  37),  excised  a 
popliteal  aneurysm.  The  vein  was  twice  wounded  during  the  dissection  and 
both  wounds  were  sutured.  The  aneurysm  was  isolated — all  collateral  branches 
were  ligated  and  the  sac  excised.  Flexion  of  the  knee  permitted  approxi- 
mation of  the  divided  ends  of  the  artery  which  were  united  by  Carrel's  suture. 
During  after-treatment  the  knee  was  kept  flexed.  After  union  was  assured  the 
knee  was  gradually  extended.  At  the  end  of  six  months  the  patient  resumed 
work.  If  it  be  impossible  to  approximate  the  divided  ends  of  the  artery  the 
gap  may  be  filled  by  implanting  a  segment  of  vein  (e.  g.,  long  saphenous). 
This  method  was  successfully  adopted  by  E.  Lexer  after  he  had  excised  an 
aneurysm  of  the  axillary  artery. 


ANEURYSM. 


709 


OBLITERATIVE   ENDO-ANEURYSMORRHAPHY    (MATAS.) 

In  situations  where  temporary  hemostasis  can  be  surely  secured  by  the 
elastic  constrictor  or  some  form  of  compressor,  or  where  all  the  main  vessels 
entering  or  leaving  the  aneurysmal  sac  can  be  secured  either  temporarily  by 
clamps  such  as  Crile's  or  permanently  by  ligatures,  Matas's  operation  is  easy 
and  efficient. 

Step  I. — After  assuring  temporary  hemostasis,  make  a  free  incision  parallel 
to  the.  long  axis  of  the  aneurysm  down  to  the  sac.  Do  not  injure  any  impor- 
tant structures. 

Step  2. — ^Freely  incise  the  sac  so  that  every  part  of  it  is  accessible  to  sight 
and  touch.     Remove  the  contents  of  the  sac  and  retract  its  walls  so  that  all  the 


P'lG.   807. — {Matas.) 

orifices  which  open  into  it  are  visible.  Note  if  there  are  two  main  orifices  un- 
connected by  a  groove  of  more  or  less  normal  arterial  wall.  If  this  is  the  case 
the  aneurysm  is  fusiform  and  suitable  for  the  obliterative  operation.  If  the 
two  openings  are  connected  by  a  groove  of  more  or  less  healthy  arterial  wall, 
note  if  this  groove  is  wide  and  contains  enough  and  sufficiently  good  tissue  to 
permit  reconstruction  of  the  artery.  If  the  groove  is  narrow  and  composed  of 
suspicious  tissue,  the  aneurysm  is  either  fusiform  or  practically  fusiform  and 
the  obliterative  operation  is  imperative.  If  the  groove  is  wide  and  satisfactory 
in  character,  the  aneurysm  is  sacculated  and  may  be  suited  to  a  reconstructive 
operation.  If  only  one  opening  is  present  in  the  sac  wall,  the  aneurysm  is  sac- 
culated and  a  reconstructive  operation  is  usually  indicated.  On  opening  the 
sac  one  may  find  it  to  be  a  false  aneurysm;  if  this  is  the  case,  find  the  opening 


7IO 


ANEURYSM. 


into  the  artery  and  close  it  by  suture  or  ligate  the  vessel,  unless  the  false 
aneurysm  is  secondary  to  the  rupture  of  a  true  one,  when  one  must  treat  the 
true  aneurysm  after  clearing  out  its  contents.  The  sac  of  a  false  aneurysm 
should  be  treated  in  the  same  fashion  as  that  of  a  true  one. 


Fig.  So8.—{Matas.) 


-esr^ 


Fig.  809. —  (Matas.) 

Step  3.— The  aneurysm  is  "fusiform"  (Fig.  807).  Withsuturesof  catgut  on  a 
curved  needle  (without  cutting  edges)  close  all  the  orifices  entering  the  sac. 
With  a  similar  suture  (continuous),  inserted  in  the  Lembert  fashion,  obliterate 


MATAS     OPERATION. 


711 


the  deeper  portions  of  the  sac,  so  that  all  the  stitches  closing  the  oritices  are  hid- 
den (Fig.  808) .  Turn  the  flaps  of  skin  plus  sac  wall  inwards  and  fix  them  by 
sutures  as  in  Figs.  809  and  810.  Remove  the  elastic  constrictor.  Apply 
dressings.  It  is  of  prime  importance  not  to  separate  the  sac  from  its  surroimd- 
ings,  as  its  walls  are  poorly  nourished  at  best,  and  sloughing  is  to  be  avoided. 
Instead  of  inverting  the  skin  and  part  of  the  sac,  the  author  has  excised  some 
of  the  excess  of  sac  wall  and  obliterated  the  rest  of  the  cavity  of  the  sac  by  means 
of  several  rows  of  continuous  Lembert-like  sutures 
of  catgut  and  closing  the  superficial  •v^'^ound  by  a 
separate  line  of  stitches. 

In  a  few  cases  the  walls  of  the  aneurysm  are  so 
thick  and  stiff  that  it  is  impossible  to  bring  them 
together  with  sutures.  In  these  cases  C.  H.  Mayo 
has  operated  as  follows:  Occlude  all  the  vessels 
entering  or  leaving  the  sac  by  surrounding  each 
with  a  purse-string  suture  of  catgut.  Very  moder- 
ate tension  on  these  sutures  suffices.  Next  place  a 
layer  of  iodoform  gauze  over  the  bottom  of  the  sac 
and  fix  it  in  place  by  a  continuous  suture  of  catgut. 
In  the  same  manner  fix  layer  upon  layer  of.  the 
gauze  in  place,  bringmg  the  end  of  each  piece  of 
gauze  out  of  the  wound.  Close  the  skin  wound 
except  where  the  gauze  protrudes.  Leave  the  gauze 
in  situ  until  the  catgut  is  absorbed.  The  ca\aty 
soon  closes  satisfactorily. 

Abbe's  case  of  obliterative  anuerysmorrhaphy 
("Annals  of  Surg.,"  July,  1908,  p.  12)  for  gluteal 

aneurysm  is  ver>'  instructive.  "A  young  Russian  of  twenty-four  years  had 
been  developing  for  three  months  right  sciatic  neuralgia  wdth  disability  in 
walking  and  some  swelling  of  his  foot.  A  pulsating  tumor  of  the  right  gluteal 
region  prevented  his  l>ing  on  that  side  also.  The  man  had  never  had  syphilis, 
but  acknowledged  gonorrhoea.  His  heart  showed  a  blowing  aortic  murmur. 
Examination  showed  a  spherical,  pulsating  tumor,  three  inches  in  diameter, 
beneath  the  gluteus  muscle  at  the  sciatic  notch,  where  its  pressure  had  caught 
the  sciatic  nerve,  and  held  it  tightly  against  the  bone — hence  the  neuralgia. 

"  It  was  a  particularly  good  case  for  operation  by  the  plastic  method,  because 
ligation  of  the  internal  iliac,  while  it  would  temporarily  arrest  the  current,  would 
allow  free  anastomosis  and  possible  return ;  meanwhile  leaving  the  distended  sac 
to  continue  sciatic  pressure. 

"  On  May  21,  1906,  I  opened  the  iliac  fossa  and  threw  a  temporary  silk  liga- 
ture about  the  internal  iliac  artery,  which  was  held  as  a  loop  by  my  assistant, 
Dr.  W.  S.  Schley,  who  drew  it  up  against  his  index  finger-tip,  so  as  to  avoid 
crushing  it  by  tight  ligation.  This  compression  at  once  stopped  pulsation  in 
the  tumor.     I  then  incised  over  the  tumor,  and  separated  the  gluteus.     The 


Fig.  810. — (Matas.) 


712  ANEURYSM. 

sac  was  well  distended  and  easily  isolated.  Its  neck  tilled  the  uppermost 
corner  of  the  sciatic  notch.  On  compression,  after  the  pulsation  had  been 
stopped  from  above,  it  emptied,  and  quickly  filled  again.  By  inference,  this 
must  have  been  by  anastomosis,  as  the  iliac  artery  was  quite  occluded  by  the 
silk  loop. 

"Seeing  no  way  to  keep  it  entirely  empty;  I  ventured  to  cut  it  freely  open, 
and  relied  on  instant  internal  pressure  to  stop  loss  of  blood.  I  first  plugged  the 
opening  of  the  gluteal  artery  with  my  index  finger-tip,  and  found  no  other 
bleeding  occurred.  I  was  then  able  to  dry  its  walls  and  see  that  they  were  firm, 
with  good  serous  lining.  On  releasing  my  finger  pressure  ever  so  little,  a  sharp 
flow  of  blood  followed,  but  not  in  pulsating  current.  I  now  began  a  continuous 
suture  of  the  internal  wall,  with  fine  chromicized  catgut,  first  fixing  it  by  a  knot 
just  above  my  finger-tip.  The  next  stitches  were  placed  so  as  to  catch  in  the  sac 
wall,  on  both  sides  of  my  finger-tip,  which  I  drew  back  as  I  quickly  tightened 
them,  thus  sealing  up  the  deepest  part  of  the  funnel-shaped  cavity.  After 
placing  the  first  four  deep  stitches  there  was  no  bleeding,  and  I  leisurely  secured 
one  wall  against  the  other  by  continuous  back  and  forth  suturing,  with  the  same 
thread.  I  even  continued  this  until  I  had  obliterated  the  entire  sac,  and  closed 
the  superstructures,  with  no  additional  knot.  The  silk  thread  was  removed 
from  the  iliac.  The  wound  was  bloodless.  The  patient  made  an  immediate 
recovery.  The  patient  had  no  recurrence  of  tumor  or  sciatic  pain  up  to  three 
months  after  operation." 

RECONSTRUCTIVE  ENDO-ANEURYSMORRHAPHY  (MATAS.) 

Steps  I  and  2  are  the  same  as  in  the  preceding  operation. 

(a)  The  aneurysm  is  sacciform.  Only  one  well-defined  opening  is  visible 
entering  the  sac.  Close  the  opening  by  a  line  of  sutures  introduced  in  the 
Lembert  fashion.  These  sutures  should  be  of  No.  i  silk  impregnated  with 
sterile  vaseline  and  should  be  introduced  by  means  of  the  finest  possible  intes- 
tinal needles.  (Curved  needles  will  be  most  convenient.)  Before  suturing,  the 
parts  to  be  sutured  should  be  douched  with  salt  solution  or  coated  wnth  vaseline 
(see  Arteriorrhaphy) .     Obliterate  the  sac  as  in  the  obliterative  operation. 

Matas  originally  closed  the  communication  between  the  artery  and  the  sac 
with  catgut,  but  the  method  described  above  is  better. 

The  author  operated  (using  catgut  throughout)  in  one  case,  and  while  the 
aneurysm  was  cured  he  feels  sure  that  the  reconstruction  of  the  artery  must  have 
failed  as  the  catgut  stitches  are  well  calculated  to  cause  obliteration  of  the 
vessel.  Even  if  the  artery  ultimately  becomes  obliterated,  it  probably  closes 
somewhat  slowly  and  gives  time  for  collateral  circulation  to  become 
established. 

(b)  The  aneurysm  is  sacciform,  but  there  are  apparently  two  openings  into 
the  sac  connected  by  a  suflficiently  wide  groove  of  healthy  arterial  wall.  After 
douching  the  groove  and  the  openings  with  salt  solution  and  smearing  them  with 


MATAS     OPEIL\TION. 


713 


vaseline  (see  Arteriorrhaphy) ,  pass  the  ends  of  a  piece  of  a  soft  rubber  catheter 
into  the  two  arterial  openings  and  let  the  tube  lie  in  the  groove  (Figs.  811  and 
812).  Have  a  loop  of  thread  round  the  catheter  with  which  to  extract  it  when 
it  has  served  its  purpose.  With  very  fine  silk  sutures  (vaselined)  on  fine  round 
needles  stitch  the  sac  on  one  edge  of  the  groove  (using  healthy  tissue)  to  the  cor- 
responding edge  on  the  other  side  of  the  groove,  over  the  catheter.  Extract 
the  catheter  and  tighten  the  sutures.  If  an  extra  stitch  seems  indicated,  in- 
sert such.  Slowly  remove  the  elastic  constrictor  (or  temporary  hemostatic 
agent).     If  any  bleeding  takes  place  at  the  line  of  suture,  stop  it  by  one  or 


Fig.  Sii.~{Afatas.) 


more  extra  sutures.  Obliterate  the  rest  of  the  sac  as  in  the  obliterative 
operation. 

W.  J.  Frick  and  the  author  have  each  performed  this  operation  using  catgut 
as  recommended  originally  by  Matas  instead  of  vaselined  silk,  in  both  cases 
the  aneurysm  was  cured,  but  as  the  ankle  pulse  was  not  to  be  felt  either  before 
or  after  the  operation  there  is  no  proof  as  to  the  success  of  the  reconstruction 
of  the  artery.  Personally,  the  author  thinks  that  obliteration  of  the  vessel  prob- 
ably occurred  due  to  the  kind  of  catgut  used. 

When  applicable,  the  author  believes  one  or  other  of  the  methods  of  Matas 
superior  to  all  others  in  the  treatment  of  aneurysm. 

Macewen's  Operation. — In  cases  of  otherwise  inoperable  aneurysm  Mac- 
ewen  has  endeavored  (successfully  in  some  cases)  to  assist  nature  in  forming  a 
"white  blood-clot"  on  the  walls  of  the  sac.  The  operation  consists  in  pushing 
long,  delicate,  finely  polished  steel  pins,  like  ladies'  hat  pins,  into  the  sac  and 


714 


ANEURYSM. 


through  its  cavity  so  as  to  touch  but  not  penetrate  the  inner  surface  of  the  sac 
on  the  opposite  side.  The  current  of  blood  acting  on  the  pins,  makes  them  quiver 
and  continuously  scratch  the  intima.  On  the  scratched  intima  a  firm  white 
blood-clot  is  deposited  which  may  become  organized  and  result  in  a  cure. 
Macewen  recommends  that  the  scarification  be  carried  out  for  about  ten  minutes 
at  one  spot  and  then  that  the  pin  be  partly  withdrawn  and  applied  at  another 
point.  In  large  aneurysms  several  pins  may  be  inserted  at  the  same  time. 
"The  action  of  this  procedure  is  slow;  sometimes  it  may  be  weeks  before  any 
noticeable  thickening  of  the  coats  is  made  out;  sometimes,  on  the  other  hand,  it 


Fig.  8i2. — (Matas.) 

may  be  much  more  rapid.  The  pins  may  be  introduced  on  several  occasions; 
it  is  well  to  leave  an  interval  of  a  week  to  a  fortnight  between  each  introduction" 
(Cheyne  and  Burghard). 


ARTERIO-VENOUS  ANEURYSM. 

The  classical  and  self-evident  method  of  operatmg  on  an  arterio-venous 
aneurysm,  whether  aneurysmal  varix  or  varicose  aneurysm  is  by  ligation  of  the 
afferent  and  efferent  vessels  with  or  without  excision  of  the  sac.  This  does  well 
in  aneurysm  of  some  unimportant  vessels,  but  when  important  vessels  are  in- 
volved the  ligation  of  the  vein  is  most  dangerous  and  gangrene  is  very  liable  to 
supervene.  The  utmost  conservatism  is  in  order  and  the  lessons  taught  in  the 
laboratory  must  be  fully  utilized.  When  it  is  only  possible  to  save  one  of  the 
vessels  forming  an  arterio-venous  aneurysm,  preservation  of  the  vein  is  of 


ARTERIO- VENOUS  ANEURYSM.  715 

more  importance  than  of  the  artery;  an  exception  to  this  rule  is  found  in  the  case 
of  the  carotid  and  the  internal  jugular. 

Methods  of  Operating  on  Arterio-venous  Aneurysm  Other  than  by 
Shnple  Ligation, — If  possible  use  provisional  hemostasis  by  means  of  an  elastic 
constrictor;  if  this  is  not  possible  expose  the  afferent  and  efferent  vessels  at  an 
early  stage  of  the  operation  and  control  them  as  in  arteriorrhaphy.  Incise  the 
sac  if  one  is  present  or  separate  the  adherent  artery  and  vein  one  from  the  other. 
If  the  wounds  in  the  artery  and  vein  can  be  closed  without  too  much  narrowing 
of  their  lumen,  do  so  in  the  Carrel  fashion.  Remove  the  clamps  or  constrictors 
and  close  the  wound. 

If  the  artery  is  completely  divided  or  nearly  so,  make  an  end-to-end  arterial 
anastomosis  either  by  Murphy's  invagination  method  (the  pioneer  operation) 
or  by  Carrel's  method.  In  one  case  of  popliteal  arterio-venous  aneurysm  E. 
Lexer  excised  the  injured  portions  of  the  artery  and  vein,  and  although  there  was 
5  cm.  (2  inches)  of  separation  between  the  vessel  ends  when  the  knee  was  ex- 
tended, he  was  able  to  unite  artery  to  artery  and  vein  to  vein  with  Payr's  pros- 
thesis, when  the  knee  was  flexed.  After  six  weeks  extension  of  the  knee  was 
possible. 

Stich  ("Deutsche  Zeitsch.,  fiir  Chir.,"  xcv,  577)  extirpated  an  arterio-venous 
popliteal  aneurysm  and  united  the  divided  artery  by  Carrel's  circular  suture. 
The  operation  was  performed  as  follows:  Four-inch  incision  on  inner  side  of 
thigh  immediately  above  the  knee-joint.  Exposure  and  isolation  of  the  an- 
eurysmal tumor  which  was  a  sacciform  dilatation  of  the  popliteal  artery.  The 
vein  was  torn  during  an  attempt  to  separate  it;  as  a  result  it  was  necessary  to 
resect  i  1/2  inches  of  the  vein  at  the  level  of  the  aneurysm.  The  artery  com- 
municated with  both  the  vein  and  the  aneurysm  sac.  Suture  of  both  openings 
in  the  artery  would  have  produced  too  much  stenosis,  so  Stich  resected  a  short 
segment  of  the  artery  and  united  its  divided  ends  by  Carrel's  method.  Slight 
flexion  of  the  knee  permitted  easy  approximation  of  the  ends  of  the  artery. 
During  the  after-treatment  the  knee  was  kept  slightly  flexed.  Three  months 
after  operation  the  patient  was  found  to  be  well. 

When,  after  separation  of  the  unnatural  anastOi-nosis  between  artery  and 
vein,  so  much  tissue  is  lost  that  direct  end-to-end  anastomosis  is  impossible,  a 
segment  of  another  and  unimportant  vessel  may  be  implanted.  E.  Lexer  has 
used  a  segment  of  the  long  saphenous  vein  to  replace  a  segment  of  the  axillary 
artery. 


CHAPTER  LXIV. 
LIGATION  OF  ARTERIES  IN  CONTINUITY. 

In  the  succeeding  pages  the  ligation  of  but  a  few  of  the  principal  arteries  is 
described.  These  are  the  vessels  which  occasionally  call  for  ligation  in  actual 
practice.  At  the  present  day  operations  for  the  tying  of  other  vessels  are  almost 
exclusively  valuable  as  anatomic  exercise  and  hence  have  no  place  in  this  work. 

A  few  general  remarks  on  methods  of  ligating  arteries. 

1.  Refresh  the  memory  regarding  the  anatomic  details  of  the  region  to  be 
invaded. 

2.  Place  the  limb  in  good  position  and  mark  on  it  the  line  of  the  artery.  A 
line  of  scratches  or  very  shallow  incisions  is  the  best  mark  to  make. 

3.  Steady  the  skin  with  the  left  hand.  This  is  important,  as  in  making 
the  incision  the  skin  will  slide  on  the  deep  structures  and  the  "marked  line" 
will  no  longer  correspond  to  the  artery.  Make  a  clean  incision  through  the 
skin  and  superficial  fascia.     The  incision  usually  must  be  2  i  /  2  to  3  inches  long. 

Precision  in  work  is  required,  hence  very  short  incisions  are  objectionable. 
Free  access  is  absolutely  requisite. 

4.  Retract  or  doubly  ligate  and  divide  all  vessels  which  come  in  the  way. 
Pick  up  thin  layers  of  the  deep  structures  in  forceps  on  each  side  of  the  line  of 
incision  and  thus  elevate  a  transverse  fold  of  the  tissue  which  becomes  emphy- 
sematous and  can  be  safely  cut.  Continue  this  proceeding,  dividing  the  tissues 
layer  by  layer  until  the  artery  in  its  sheath  is  reached.  WTien  penetrating  the 
deep  parts  through  intermuscular  septa  the  dissection  may  be  accomplished 
with  the  handle  of  the  scalpel. 

As  the  wound  is  deepened  its  edges  must  be  held  apart  by  blunt  retractors; 
but  the  retraction  must  be  made  with  care,  otherwise  the  depth  of  the  wound 
will  be  distorted  and  the  Hne  of  the  artery  lost.  The  deep  structures  must  be 
divided  as  extensively  as  the  skin  or  nearly  so. 

5.  The  artery  being  reached  must  be  distinguished  from  neighboring  veins 
and  nerves.  The  nerves  appear  as  white,  firm,  solid  cords.  The  veins  when 
empty  look  like  thin  fibrous  sheets,  when  full  they  are  soft,  easily  compressed, 
and  when  compressed  they  fill  up  on  the  distal  side.  The  veins  are  larger  than 
and  often  overlap  the  arteries,  and  through  them  the  pulsation  of  the  artery 
may  be  felt.  Occasionally  nerves  may  transmit  pulsation  in  a  most  deceiving 
manner  from  the  artery  to  the  palpating  finger.  Arteries  feel  to  the  finger  like 
fairly  firm  tubes,  and  they  pulsate.  This  pulsation  may,  however,  be  feeble 
under  certain  circumstances  or,  as  already  noted,  it  may  be  transmitted  to  nerves, 
etc.,  and  thus  error  may  arise.     During  every  step  of  the  operation  from  skin 

716 


LIGATION    OF   ARTERIES. 


717 


incision  to  exposure  of  the  vessel  be  careful  to  recognize  every  anatomic  guide 
either  by  eyesight  or  by  touch.  Farabeuf,  speaking  of  the  importance  of  touch, 
says  the  surgeon  should,  in  the  dissecting-room,  "accustom  himself  to  ligate 
certain  arteries  with  his  eyes  in  the  air  and  his  fingers  in  the  wound  as  soon  as 
the  superficial  incision  has  been  made."  Accurate  hemostasis  and  a  dry 
wound  are  of  much  importance. 


Fig.  813. — (Esmarch  and  Kowalzig.) 


6.  The  artery  lies  in  a  fibrous  sheath  much  as  a  tendon  does.  This  sheath 
must  be  opened,  \\lien  the  fibrous  sheath  has  been  exposed,  with  dissecting 
forceps  pick  up  a  transverse  fold  of  it  (Fig.  813).  If  the  forceps  are  applied 
from  side  to  side  so  as  to  pick  up  a  longitudinal  fold  of  the  sheath  they  may 
include  in  their  bite  a  portion  of  the  wall  of  the  vessel. 

Apply  a  scapel  with  its  flat  surface  to  the  vessel  and  cut  a  notch  in  the 
elevated  fold  of  sheath,  parallel  to  the  vessel. 
Lay  aside  the  knife.  Do  not  let  loose  the  forceps. 
With  the  blunt  point  of  a  probe,  director,  or 
aneurysm  needle  insinuated  through  the  opening 
in  the  sheath  separate  the  sheath  from  the  vessel 
for  a  short  distance  and  catch  the  edges  of  the 
wound  in  the  sheath  with  fine-pointed  hemostasis 
forceps;  unless  this  is  done  it  may  be  difficult  to 
find  the  opening  in  the  sheath  again.  Pass  the 
aneurysm  needle  between  the  sheath  and  the  artery 
half  way  round  the  vessel  in  one  direction,  and 
then  do  the  same  in  the  opposite  direction.  In 
this  manner  about  1/4  inch  of  the  artery  is  com- 
pletely separated  from  its  sheath.  From  the  vein 
side  of  the  artery  pass  the  aneurysm  needle  com- 
pletely round  the  vessel  under  the  sheath.  When  the  eye  of  the  instrument 
protrudes  at  the  opposite  side  of  the  vessel,  thread  it;  withdraw  the  needle 
and  thus  place  the  ligature  in  position.  If  the  needle  is  armed  with  a  stout 
ligature  before  being  passed  the  thread  greatly  impedes  the  manoeuvre. 
On  the  other  hand,  it  is  often  difficult  to  thread  the  needle  after  it  has  been 
passed.  To  avoid  these  difficulties  the  author  arms  the  needle  with  a  fine  thread 
of  silk  or  hemp,  passes  the  needle  thus  armed  round  the  vessel,  picks  up  the 


Fig.  814. 


7l8  LIGATION    OF   ARTERIES    IN    CONTINUITY. 

loop  of  the  fine  thread,  withdraws  the  needle,  passes  a  stout  ligature  through 
the  loop,  withdraws  the  loop,  and  so  brings  the  ligature  into  position  (Fig.  814). 
If  too  much  of  the  artery  is  separated  from  its  sheath  nutrition  is  impaired  and 
the  vessel  may  necrose. 

7.  The  ligature  may  be  of  catgut,  silk,  hemp,  tendon,  ox-aorta,  etc.,  ac- 
cording to  the  whim  of  the  operator.  Tie  the  ligature  in  a  reef  knot.  If  catgut 
is  used  make  three  ties.  Some  surgeons  recommend  that  the  ligature  be  tied 
tightly  enough  to  rupture  the  intima.  This  is  not  necessary,  all  that  is  requisite 
is  to  have  the  lumen  obliterated  and  the  inner  surfaces  of  the  intima  in  contact. 

8.  Close  the  wound  accurately.  Apply  dressings.  Keep  the  limb  at  rest, 
elevated  and  warm. 

LIGATION  OF  THE  COMMON  CAROTID  ARTERY. 

(A)  Ligation  at  the  site  of  election,  i.  e.,  above  the  omo-hyoid  muscle  in  the 
carotid  triangle. 

Place  the  patient  on  his  back  with  a  firm  pillow  under  the  shoulder  and  neck 
with  his  chin  directed  upwards  and  towards  the  opposite  side  (the  head  moder- 
ately extended  and  rotated). 


Ext.  jugular 
Sterno-mastoid 


Fig.  815. —  (Kocher.) 

Step  I. — ^Method  A. — Make  a  three-inch  incision  along  the  anterior  margin 
of  the  sterno-mastoid  having  its  mid-point  opposite  the  cricoid  cartilage.  Divide 
the  subcutaneous  tissue  and  the  platysma  throughout  the  length  of  the 
wound.     Do  not  unnecessarily  injure  the  superficial  veins. 

Method  B. — Kocher's  Incision. — At  the  level  of  the  cricoid  cartilage 
make  a  three-inch  horizontal  incision  through  the  skin  and  platysma.  The 
incision  follows  the  direction  of  the  folds  in  the  neck  and  is  slightly  oblique  from 
above  downwards  and  inwards  (Fig.  815). 

The  centre  of  the  incision  must  correspond  to  the  anterior  edge  of  the  stemo- 


COMMON    CAROTID. 


719 


mastoid.     Divide  the  fascia  covering  the  sterno-mastoid.     Retract  the  edges 
of  the  wound. 

Step  2. — Retract  the  sterno-mastoid  outwards.  Recognize  the  anterior  belly 
of  the  omo-hyoid.  Palpate  for  the  carotid  tubercle  (transverse  process,  sixth 
cervical  vertebra)  at  the  angle  formed  by  the  crossing  of  the  sterno-mastoid  and 
the  omo-hyoid.     The  artery  crosses  the  tubercle.     Observe  a  nerve  running 


Plo'jSfv.a  myoiiies  m. 

—  Su/jpr-'icial  layer 
jf  Uet  f.  fascia 
Dt-sct^ndens  hypogiosi' 

''-A-— T ■ • w»_M(dJ(o  stftrno-mastaid 


Arttfior  Lifclly  of  cmo-hyoid  m. 
Storno-mastoid  m. 
Incisions  into  carotid  sheaih  arid  Uue  arttnr:!  thoafh 
Ansa  hypoglossi  (n  ) 
Middle  ste(no-rT!ar.tuid  a 


Fig.  816. —  (Deaver.) 

dovi^nwards  throughout  the  wound  (descendens  noni) ;  it  lies  directly  on  the  sheath 
of  the  carotid  vessels.  Open  the  common  sheath  of  the  carotid  vessels  to  the 
inner  side  of  the  descendens  noni  nerve,  and  retract  outwards  the  nerve  and  the 
corresponding  portion  of  the  sheath.  (Fig.  816). 

Step  3. — Note  the  internal  jugular  vein  lying  to  the  outer  side  of,  and  some- 
times overlapping  the  artery.  The  vagus  nerve  lies  behind  and  between  the 
artery  and  vein.  Pass  an  aneurysm  needle  round  the  artery  from  the  outer 
side  inwards.     Beware  of  including  the  vagus  nerve  in  the  ligature. 


'20 


LIGATION    OF   ARTERIES    IN    CONTINUITY. 


LIGATION  BELOW  THE  OMO-HYOID  MUSCLE. 

(B)  Here  the  artery  is  deeply  seated  and  is  difficult  to  expose. 

Step  I. — ^Method  A. — Kocher's  Incision. 

Method  B. — Make  a  3-inch  incision  having  its  lowest  end  3/4  inch  external 
to  the  sterno-clavicular  articulation.  This  incision  is  parallel  to  the  sterno- 
mastoid  and  lies  between  its  sternal  and  clavicular  portions. 


\u.     . .rr*-— *„'  . 


>n 

0 
< ) 

0     0 

H    P? 

^ 

0^ 

(^ 


Method  C. — Make  a  3-inch  incision  along  the  anterior  margin  of  the  stemo- 
mastoid  from  the  level  of  the  cricoid  cartilage  downwards. 

Step  2. — ^Method  A. — Incision  (b)  has  been  made.  Divide  the  platysma 
throughout  the  length  of  the  wound.  Penetrate  between  the  two  heads  of 
the  sterno-mastoid,  until  the  internal  jugular  vein  is  seen.     Retract  outwards 


COMMON    CAROTID.  721 

the  vein  and  the  clavicular  portion  of  the  stemo-mastoid.  Retract  inwards  the 
sternal  portion  of  the  sterno-mastoid  and  with  it  the  sterno-hyoid  and  sterno- 
thyroid muscles.  The  vagus  lies  to  the  inner  side  of  the  vein,  the  carotid  artery 
lies  somewhat  more  internal  and  deeper,  under  the  vein  (Fig.  817). 

Method  B. — Incision  (a)  or  (c)  has  been  made.  Divide  the  deep  fascia  along 
the  anterior  edge  of  the  sterno-mastoid.  Expose  the  sterno-hyoid  and  sterno- 
thyroid muscles.  Retract  the  latter  muscles  inwards  and  the  former  outwards. 
This  exposes  the  carotid  sheath.  The  descendens  noni  nerve  is  not  seen  on  the 
front  of  the  sheath  in  this  region  (Da  Costa).  Feel  the  carotid  tubercle  in  the 
upper  part  of  the  wound.  As  the  artery  crosses  the  tubercle  it  is  a  valuable 
landmark. 

During  the  exposure  of  the  carotid  sheath  a  number  of  veins  may  require 
ligation  and  division. 

Step  3. — Open  the  sheath  on  its  inner  side,  clear  the  vessel,  and  pass  the 
aneurysm  needle  around  it  from  without  inwards,  carefully  avoiding  the  vagus 
nerve. 

Remarks. — Ligation  of  the  common  carotid  may  be  indicated  in  cases  of 
wounds,  aneurysm,  malignant  neoplasms  (in  order  to  starve  the  growths), 
and  in  hydrocephalus. 

Cerebral  disturbances  frequently  follow  ligation  of  the  common  carotid. 
These  accidents  have  become  less  frequent.  LeFort's  statistics  show  45  per  cent. ; 
Siegrist's  38  per  cent.;  Jordan  accepts  25  per  cent,  as  being  correct;  De 
Fourmestraux  (French  Congress  of  Surg.,  1908)  has  experienced  the  accident 
in  21  per  cent,  of  his  personal  cases,  while  in  such  operations  as  for  exophthalmos 
that  surgeon's  death  rate  fell  to  5  or  6  per  cent.  De  Fourmestraux  thinks  the 
cerebral  disturbances  result  from  ascending  thrombosis  due  to  some  trifling 
infection  at  the  point  of  ligation. 

Such  being  the  case,  the  surgeon  is  always  in  doubt  whether  the  patient  will 
come  out  of  the  anaesthesia,  and  if  he  does  whether  he  will  exhibit  hemiplegia  or 
progressive  cerebral  softening.  In  view  of  these  difficulties  Jordan  recom- 
mends partial  contriction  of  the  artery  for  about  forty-eight  hours  before  defi- 
nite ligation.  From  experiments  Jordan  finds  that  it  is  possible  to  apply  a 
tape  or  coarse  catgut  ligature  around  the  vessel  sufficiently  firmly  to  stop  the 
peripheral  pulse  but  sufficiently  gently  not  to  injure  the  intima.  This  con- 
striction can  be  kept  up  for  two  days  without  coagulation  taking  place,  and 
when  the  constrictor  is  removed  the  circulation  soon  becomes  normal  again. 
The  preliminary  tentative  ligation  must  be  accomplished  under  local  anaesthesia 
to  permit  of  immediate  observation  of  any  cerebral  symptoms  which  may 
develop.  If  the  constrictor  causes  disturbance  it  may  be  lessened  or  removed. 
By  gradual  increase  of  constriction  it  may  be  possible  to  increase  collateral 
circulation.  If  no  objectionable  symptoms  develop,  the  ligation  may  be  made 
complete  and  permanent. 

Matas  attains  the  same  ends  by  bending  a  narrow  strip  of  metal  around 
the  vessel  %vith  pressure  sufficient  to  stop  the  blood  current  but  insufficient  to 
46 


722 


LIGATION    OF   ARTERIES    IN    CONTINUITY. 


injure  the  vessel  wall.  This  metal  strip  is  buried;  if  no  symptoms  develop  it  is 
left  in  situ;  if  symptoms  develop  the  wound  is  reopened  and  the  metal  removed. 

Hydrocephalic  children  bear  ligation  of  the  common  carotid  well.  In  these 
cases  both  arteries  must  be  tied,  but  ten  days  must  elapse  between  the  operations 
(Ballance). 

Ransohoff  ("Surg.,  Gyn.,  Obstet.,"  August,  1906)  advocates  ligation  of  the 
common  carotid,  external  carotid,  and  superior  thyroid  arteries  in  cases  of 
pulsating  exophthalmos. 


Temporal  art 
Int.  max.  art 


Omo-hyoid 
Sterno-thyroid 


Pharyngeal  art. 

Lingual  art. 
!  Facial  art. 


Hyo-glossus 
I  Digastric 

Myo-hyoid 


Fig.   <Si8. — iEsmarrJi.) 


Instead  of  permanently  occluding  the  common  carotid,  temporary  occlusion 
may  be  employed  to  prevent  hemorrhage  during  various  operations.  For  this 
purpose  Fowler  threw  a  tape  around  the  vessel,  securing  the  tape  by  forceps, 
while  Crile  successfully  uses  his  special  forceps. 

LIGATION  OF  INTERNAL  JUGULAR  VEIN. 

Ligation  of  the  vein  may  be  necessary  in  cases  of  sigmoid  sinus  thrombosis. 
The  operation  is  practically  the  same  as  for  ligation  of  the  carotid.  Particular 
care  must  be  exercised  in  passing  the  ligature  around  the  vein,  as  its  walls  are 
very  thin  and  its  size  varies  greatly  during  expiration  and  inspiration. 

LIGATION  OF  THE  EXTERNAL  CAROTID  ARTERY. 

Position  of  patient  as  in  ligation  of  the  common  carotid. 

Method  A. — Step  i. — Make  an  incision  about  2  1/2  to  3  inches  in  length 


EXTERNAL    CAROTID. 


723 


along  the  anterior  margin  of  the  sterno-mastoid.  The  centre  of  the  incision 
must  be  opposite  the  greater  honi  of  the  hyoid  bone.  Divide  the  platysma  and 
the  deep  fascia  (attached  to  the  sterno-mastoid)  throughout  the  length  of  the 
wound.     Retract  the  sterno-mastoid  outwards. 


Dig^astric   m. 
Bi/po^hssal  mrm. 


G/ieat  cornu  or  /if/oid  iom. 

3:t.  carotid  arlenj. 

-Re trading  facial veinic. 

Sup.  thyroid  art 
/letractin^  sterm-mastoidm. 

Fig.  819. 

;  Step  2. — ^Find  the  posterior  belly  of  the  digastric  muscle  in  the  upper  part  of 
the  wound  (Fig.  818).  Find  the  hypoglossal  nerve  a  little  below  the  digastric 
(Fig.  819).  Retract  these  structures  upwards.  Avoid  injuring  the  facial  and 
superior  thyroid  veins. 


Hypoglossal  n 
Greater  horn 
hyoid 
Sup.  laryn- 
geal n. 
Ext.  carotid 
Spu.  thyroid  atr. 


Fig.  820. — {Kocher.) 


Sp.  access- 

sory  n. 
Auricularis 
magnus  n. 
Ext.  jug.  V. 

Descendens'noni 

Int.  jugular 

Sterno-masto  i  d 


Xote  the  tip  of  the  great  cornu  of  the  hyoid  bone  and  expose  the  artery 
opposite  this  guide.  As  the  internal  carotid  has  been  mistaken  for  the  external, 
it  is  very  wise  to  demonstrate  one  of  the  branches  of  the  external  carotid  before 
passing  a  ligature  around  the  vessel. 


724  LIGATION    OF   ARTP:RIES    IN    CONTINUITY. 

Step  3. — Pass  a  ligature  around  the  vessel  from  without  inwards,  avoiding 
the  vein  which  lies  to  the  outer  side  of,  and  frequently  overlaps  the  vessel,  and 
also  avoiding  the  superior  laryngeal  nerve  which  runs  behind  it. 

Method  B. — Kocher's  Incision. — Step  i. — Choose  a  point  on  the  anterior 
margin  of  the  sterno-mastoid  muscle,  one  finger's  breadth  below  the  angle  of  the 
jaw.  Make  a  slightly  oblique  horizontal  incision  having  its  centre  at  the  above 
point  (Fig.  820).  After  exposing  the  anterior  edge  of  the  sterno-mastoid  the 
operation  becomes  practically  the  same  as  Method  A. 

Indications. — (a)  Hemorrhage  from  wounds  of  branches. 

(b)  As  a  preliminary  step  in  the  removal  of  some  tumors,  e.  g.,  of  the  retro- 
pharyngeal space. 

(c)  Aneurysm. 

(d)  Occasionally  to  prevent  hemorrhage  from  the  middle  meningeal  artery 
during  operations  on  the  Gasserian  ganglion. 

Remarks. — Hearn  ligates  the  external  carotid  as  a  preliminary  to  excision 
of  the  superior  maxilla  for  malignant  disease  and  states  that  in  doing  so  he 
exposes  some  enlarged  lymph  nodes  which  would  otherwise  escape  notice. 
Matas  thinks  it  important  to  place  the  ligature  well  above  the  bifurcation  of  the 
common  carotid  to  avoid  the  danger  of  cerebral  embolism. 

LIGATION  OF  THE  INTERNAL  CAROTID  ARTERY. 

Step  I. — Expose  the  external  carotid  (see  p.  722).  The  internal,  at  its  origin, 
lies  a  little  behind  and  to  the  outer  side  of  the  external  carotid. 

Step  2. — Gently  retract  the  external  carotid  inwards.  Open  the  sheath  of 
the  internal  carotid  immediately  over  the  artery.  Remember  that  the  artery, 
the  internal  jugular  vein  and  the  vagus  occupy  the  same  sheath,  the  vein  being 
external  and  the  nerve  behind  and  between  the  vessels.  Pass  the  aneurysm 
needle  around  the  artery  from  without  inwards. 

Indications. — For  intra-cranial  aneurysm  of  vessels  other  than  the  menin- 
geal. For  hemorrhage,  e.  g.,  after  tonsillectomy.  If  the  operation  seems 
called  for  because  of  hemorrhage  after  tonsillectomy,  expose  and  apply  pressure 
to  the  external  carotid — if  this  controls  the  bleeding  it  must  be  from  the  tonsillar 
artery  and  ligation  of  the  internal  carotid  becomes  unjustifiable. 

Lingual  Artery. — The  lingual  artery  arises  from  the  external  carotid  at  the 
level  of  the  great  horn  of  the  hyoid  bone  (Fig.  818).  After  running  a  curved 
course  it  dips  under  the  hyoglossus  muscle  and  proceeds  forwards  parallel 
and  close  to  the  greater  horn  of  the  hyoid.  It  is  crossed  by  the  digastric  and 
stylohyoid  muscles.  The  hypoglossal  nerve  runs  parallel  to  the  lingual  artery, 
but  is  more  superficial,  being  separated  from  it  by  the  hyoglossus  muscle. 

The  Operation. — Step  i. — ^Method  A. — Make  an  incision  parallel  to  and 
about  I  1/2  inches  above  the  great  horn  of  the  hyoid.  Divide  the  skin  and  the 
platysma.  Divide  the  deep  fascia.  Ligate  and  divide  or  retract  any  veins 
which  come  in  the  way. 


SUPERIOR    THYROID.  725 

Step  2. — Retract  the  submaxillary  gland  upwards  (Fig.  821).  Expose  the 
posterior  belly  of  the  digastric  under  which  lies  the  hypoglossal  nerve.  The 
nerve  forms  a  good  guide  to  the  hyoglossus  muscle  on  which  it  lies.  The 
lingual  vein  may  lie  either  superficial  to  the  hyoglossus  or  beneath  it  along  with 
the  artery.     Avoid  injury  to  the  nerve  and  vein. 

Step  3. — Carefully  divide  the  hyoglossus  (on  a  director)  between  the  hypo- 
glossal nerve  and  the  great  horn  of  the  hyoid.  This  exposes  the  lingual  artery, 
which  is  accompanied  by  a  vein  or  vena  com  lies. 

Method  B. — Kocher. — Step  i. — Make  an  incision  parallel  to  and  immedi- 
ately above  the  hyoid  bone,  from  the  anterior  edge  of  the  sterno-mastoid  to 
the  body  of  the  hyoid. 

Divide  skin,  platysma,  and  fascia,  as  if  to  lay  bare  the  great  horn  of  the 
hyoid.  The  digastric  and  stylohyoid  muscles  and  the  submaxillary  gland 
appear  in  the  upper  part  of  the  wound. 


Hypo-glossal  n. 

Mylo-hyoid  m. 


Lingual  art. 


Fig.  821. — Ligation  of  left  lingual  artery. — {Esmarch  and  Kowalzig.) 
d,  Digastric;  Oh,  Great  horn  hyoid;  hg,  Hyoglossus;  gl,  Salivar}'  gland;  st,  Stylohyoid'.. 

Step  2. — Let  the  asistant  exercise  vertical  pressure  on  the  great  horn  of  the 
hyoid  on  the  opposite  side  of  the  neck;  this  pushes  the  bone  into  the  wound. 
Seize  the  horn  of  the  hyoid  with  a  hook  and  pull  it  up,  so  that  the  whole  region 
becomes  superficial.  Note  the  fibres  of  the  hyoglossus  muscle  running  upwards 
and  the  hypoglossal  nerve  passing  from  behind  forwards  over  the  muscle. 

Step  3. — With  utmost  care  divide  the  hyoglossus,  transversely,  immediately 
above  the  bulbous  end  of  the  great  horn  of  the  hyoid.     This  exposes  the  artery. 

Indication  for  ligation  of  the  lingual  artery: 

(i)  Preliminary  to  excision  of  the  tongue.  (2)  To  starve  malignant  neo- 
plasms in  territory  supplied  by  the  artery.     (3)  To  stop  hemorrhage. 

Superior  Thyroid  Artery. — Kocher's  Method. — Ligation  of  the  superior 
thyroid  artery  is  done  at  the  top  of  the  upper  horn  of  the  thyroid  gland. 

Step  I . — (A)  Make  an  incision  parallel  to  and  immediately  above  the  hyoid 
bone,  from  the  anterior  edge  of  the  sterno-mastoid  to  the  body  of  the  hyoid. 
Divide  the  skin,  platysma,  and  fascia.  Retract  the  lower  edge  of  the  wound 
strongly  downwards. 

(B)  If  the  upper  horn  of  the  thyroid  gland  does  not  extend  far  up  the  neck, 
make  the  incision  3/4  inch  lower,  corresponding  to  the  upper  margin  of  the 
thyroid  cartilage. 


726  LIGATION    OF   ARTERIES    IN    CONTINUITY. 

Step.  2 — ^Feel  the  pulsations  of  the  anterior  branch  of  the  artery  on  the  me- 
dian-anterior side  of  the  upper  horn  of  the  thyroid  gland  beside  the  larynx. 
Follow  this  vessel  over  the  apex  of  the  gland  until  the  main  artery  is  reached. 

Step  3. — Ligate  the  main  artery. 

The  only  indication  for  ligation  of  the  superior  thyroid  artery  is  hyperthy- 
roidism. C.  H.  Mayo,  Stamm  and  others  prefer  to  ligate  the  upper  pole  of 
the  thyroid  gland,  thus  tying  the  branches  of  the  superior  thyroid  artery  in  a 
mass  ligature. 

LIGATION  SUPERIOR  POLE  OF  THYROID. 

If  general  anaesthesia  is  to  be  used  administer  morphine  gr.  1/6  with  atropine 
gr.  i/ioo  about  half  an  hour  before  operation. 

Step  I.  Make  a  transverse  incision,  if  possible  in  a  natural  crease,  two  and 
one-half  inches  in  length,  crossing  the  central  part  of  the  thyroid  cartilage. 
The  cut  divides  the  skin  and  platysma  and  gives  access  to  the  gland  on  both 
sides. 

Step  2. — Retract  the  inner  border  of  the  sterno-mastoid  outwards  and  ex- 
pose the  omo-hyoid.  Retract  the  omo-hyoid  upwards  and  inwards.  Under 
the  omo-hyoid  lies  the  upper  pole  of  the  thyroid. 

Step  3. — ^Pass  a  ligature  (linen,  silk)  round  the  upper  pole  and  tie  it  (Fig. 
822).  If  a  vein  is  pierced  by  the  aneurysm  needle  and  causes  bleeding  pull 
upon  the  ligature  and  pass  a  second  ligature  including  more  tissue.  The 
ligature  includes  veins,  arteries,  and  gland  tissue.  There  is  no  danger  of  in- 
juring the  recurrent  laryngeal  nerve  (Mayo,  "Annals  of  Surg.,"  Dec,  1909). 

Stamm  and  Jacobson  strongly  recommend  ligation  of  the  upper  pole  in  ex- 
ophthalmic goitre  when  more  radical  operations  seem  inadvisable.  The  author 
finds  the  operation  by  no  means  diiScult. 

Inferior  Thyroid  Artery. — Step  i. — Expose  the  common  carotid  artery 
and  internal  jugular  vein  immediately  below  the  tendon  of  the  omo-hyoid. 
(Do  this  either  through  Kocher's  incision  or  through  an  incision  along  the  inner 
margin  of  the  sterno-mastoid) . 

Step  2. — Gently  retract  outwards  the  carotid  packet  of  vessels  and  nerves. 
Pull  the  tendon  of  the  omo-hyoid  upwards.  Push  the  thyroid  gland  and  the 
trachea  inwards  (i.  e.,  towards  the  opposite  side). 

Note  the  transverse  process  of  the  sixth  cervical  vertebra  (carotid  tubercle). 
Opposite  this  fixed  point  the  inferior  thyroid  artery  may  be  seen  appearing  from 
behind  the  common  carotid  at  about  the  same  level  as  the  omo-hyoid  tendon 
crosses  in  front  of  that  vessel. 

Step  3. — Ligate  the  artery  as  far  from  the  thyroid  gland  as  possible  to  avoid 
injury  to  the  recurrent  laryngeal  nerve  which  crosses  the  artery  behind  the  gland. 
Be  careful  not  to  include  in  the  ligation  the  middle  cervical  ganglion  or  the 
recurrent  laryngeal  nerve. 

The  indications  for  ligation  of  the  inferior  thyroid  artery  (and  for  the  su- 
perior as  well)  are  certain  forms  of  goitre. 


SUBCLAVIAN 


727 


Subclavian  Artery. — Place  the  patient  on  his  back,  support  the  shoulders 
on  a  pillow  so  that  the  head  may  be  extended  and  turned  to  the  opposite  side. 
Keep  the  arm  well  pulled  downwards  (when  possible  pass  the  arm  behind  the 
back  so  as  to  keep  it  in  proper  position). 


Fig,  822. — (Annals  of  Surgery.     {Mayo.) 


Step  I. — Choose  a  point  one-half  inch  above  and  one  inch  internal  to  the 
middle  of  the  cavicle.  Let  this  point  be  the  centre  of  a  three-inch  incision 
parallel  to  the  clavicle  and  extending  from  the  Trapezius  to  the  sterno-mastoid. 
In  making  this  incision  be  careful  not  to  injure  the  external  jugular  vein.  Divide 
the  skin  and  the  platysma.   Retract  the  external  jugular  outwards  or,  if  requisite, 


•28 


LIGATION    OF   ARTERIES    IN    CONTINUITY. 


divide  it  between  two  ligatures  (Fig.  823).  At  this  stage  difficulties  may  be  en- 
countered due  to  the  venous  plexus  formed  by  the  transverse  cervical  and  supra- 
scapular veins.  If  these  veins  cannot  be  retracted  out  of  the  way,  they  must  be 
ligated  and  divided.  A  dry  wound  is  essential.  Divide  the  deep  fascia  through- 
out the  extent  of  the  wound. 

Step  2. — Note  the  outer  edge  of  the  scalenus  anticus  muscle.  The  sub- 
clavian vein  lies  in  front  of  the  muscle,  the  subclavian  artery  behind  it  and  at  a 
slightly  higher  level  than  the  vein.  Pass  the  finger  along  the  edge  of  the  muscle 
until  the  scalene  tubercle  on  the  first  rib  is  felt.  The  artery  lies  immediately 
outside  and  behind  the  tubercle.  If  the  omo-hyoid  muscle  is  in  the  way,  re- 
tract it  upwards. 


.7    8    9  10 


Fig.  823. — (Farabeuf.) 
I.  Ext.  jugular  vein — retracted  outwards.     2.  Artery.     3.  First  rib.     4.  Subclav.  vein. 
5.  Supra    scap.     art.     6.  Sterno-mastoid.     7.  Scalenus    ant.     8.  Transverse    cervical    art. 
(post,  scapular).     9.  Brachial  plexus.     10.  Omo-hyoid. 


Step  3. — The  lowest  cord  of  the  brachial  plexus  lies  immediately  above  the 
artery  and  has  been  mistaken  for  it.  Systematically  expose  this  nerve  cord 
sufficiently  to  permit  of  precise  recognition  (Treves). 

Pass  the  aneurysm  needle  around  the  artery  from  above  downwards  and 
from  behind  forwards,  guiding  the  needle  with  the  finger  and  holding  the  vein 
out  of  harm's  way.     Pull  a  ligature  around  the  vessel  and  tie  it. 

Step  4. — Close  the  wound. 

Ligation  of  the  third  part  of  the  subclavian  artery  has  alone  been  described 
here  as  the  other  segments  of  the  vessel  are  unsuitable  for  and  very  rarely  re- 
quire ligation. 

Indications. — Axillary  aneurysm;  axillary  hemorrhage;  wounds;  prelimi- 
nary to  excision  of  the  scapula,  or  of  the  entire  upper  limb,  etc.,  and  as  treat- 
ment for  innominate  and  aortic  aneurysms. 

Riedel  ("Zentrallilatt  fiir  Chir.,"  1907,  No.  32)  objects  to  the  classical 
method  of  ligating  the  subclavian  because  the  work  is  not  sufficiently  guided 
by  the  eye.     He  advocates  the  following  method: 

I.  Make  an  incision  parallel  to  the  direction  of  the  great  vessels  of  the  neck 


AXILLARY. 


729 


from  the  level  of  the  transverse  process  of  the  fifth  cervical  vertebra  to  the 
middle  of  the  clavicle.     Divide  the  skin  and  platysma. 

2.  Doubly  ligate  and  divide  the  numerous  veins  which  appear-  also  the 
transversalis  coli  artery.  The  superior  nerve  trunk  soon  appears  emerging 
from  between  the  scalenus  anticus  and  medius. 

3.  Work  into  the  groove  between  the  scalenus  anticus  and  medius  (distin- 
guished one  from  another  by  the  emerging  nerve 
trunks).  Working  downwards,  expose  the 
second  and  third  nerve  trunks,  below  the  last  of 
which  lies  the  artery.  In  spite  of  the  depth  of 
the  wound,  it  is  comparatively  easy  to  sufh- 
ciently  expose  the  artery  and  to  ligate  it.  The 
whole  operation  should  be  performed  without 
introducing  the  finger  into  the  wound  (Riedel) 
unless  gloves  are  worn. 

Axillary  Artery. — Farabeuf  s  Method. — 
Place  the  patient  on  his  back  at  the  edge  of 
the  table  with  the  arm  at  right  angles  to  the  body 
extend  the  forearm  fully. 

Step  1. — ^From  the  apex  of  the  axilla  make  a  three-inch  incision  down  the 
arm,  immediately  behind  the  anterior  wall  of  the  axilla,  along  the  inner  and 
posterior  border  of  the  coraco-brachialis  (Fig.  824).  As  soon  as  the  skin  is 
divided,  the  posterior  edge  of  the  wound  retracts  and  discovers  the  brachial 
plexus  and  axillary  vein  visible  through  the  aponeurosis  (Farabeuf).     Elevate 


Fig.  824. —  (Farabeuf.) 

Do  not  either  flex  or 


(Farabeuf.) 


The  retractor  supports  the  ist  landmark,  the  coraco-brachialis  (i)   with  the  musculo- 
neous  n.     (i'):  the  director  supports  the  2nd  landmark,  the  median  n.(2.,2').  3=The  art. 


cutaneous  n.     (i') 
4=  Int.  cutaneous  n. 


ipports 
5=  Deeply  seated  small  collateral  veins. 


the  pectoralis  major  and  under  it,  /.  e.,  anterior  to  the  vessels  and  nerves,  divide 
the  fascia  so  as  to  expose  the  coraco-brachialis  muscle. 

Step  2.— Recognize  the  coraco-brachialis  muscle  (first  guide)  and  free  its 
inner  border  for  a  short  distance.  Relax  the  muscle  by  bringing  the  arm  nearer 
to  the  patient's  side.     Retract  the  muscle  forwards  with  a  blunt  hook. 


730  LIGATION   OF  ARTERIES    OF   CONTINUITY. 

Step  3. — With  the  finger  introduced  between  the  coraco-brachialis  and  the 
packet  of  vessels  and  nerves,  push  the  latter  backwards.  Very  slowly  and 
lightly  remove  the  finger.  As  this  is  done  one  cord  escapes  from  the  pocket 
and  slips  forwards  {i.  e.,  upwards,  the  patient  lying  on  his  back)  (Fig.  825).  The 
cord  lies  free;  it  does  not  perforate  the  muscle  as  the  musculo-cutaneous  nerve 
does;  it  is  the  median  nerve  (second  guide).  Isolate  the  nerve  and  retract  it 
with  the  coraco-brachialis.  The  next  cord  felt  under  the  finger  is  the  axillary 
artery,  readily  recognized  by  touch  and  sight.  In  order  to  be  sure  of  tying 
the  artery  above  where  the  circumflex  branches  off,  isolate  the  vessel  in  the  upper 
part  of  the  wound. 

Step  4. — With  the  finger  push  the  rest  of  the  axillary  vessels  and  nerves 
backwards  (the  median  nerve  is  already  out  of  the  way).  Pass  an  aneurysm 
needle  around  the  artery  from  behind  forwards. 

Brachial  Artery. — The  superficial  position  of  the  brachial  arter}'  is  such 
that  its  ligation  seems  easy,  but  the  reverse  is  the  case.  Numerous  and  rather 
humiliating  errors  have  been  reported  by  good  operators.  The  artery  is 
subject  to  abnormalities,  (a)  The  artery  may  lie  in  front  of  instead  of  behind 
the  median  nerve  (one  out  of  six  cases),  (b)  The  artery  may  divide  high  up 
and  thus  during  the  operation  two  arteries  may  be  met  instead  of  one,  each 
or  both  of  which  may  require  ligation,  (c)"  The  artery  may  be  partially  covered 
by  a  muscular  slip  given  ofif  from  the  pectoralis  major,  biceps,  coracobrachialis, 
or  brachialis  anticus." 

The  brachial  is  rarely  tied  elsewhere  than  in  the  middle  of  the  arm. 

Step  I. — With  the  forefinger  hold  a  thread  against  the  skin  of  the  deepest 
point  (the  apex)  of  the  axilla.  Hold  the  other  end  of  the  thread  (drawn  tense) 
on  the  mid-point  of  the  fold  of  the  elbow.  The  course  of  the  thread  gives  the 
line  of  the  brachial  artery. 

Step  2. — Along  the  line  of  the  artery,  make  a  2  1/2  inch  incision  through 
the  skin  on  the  inner  border  of  the  biceps.  Divide  the  fascia  covering;  the 
muscle,  thus  exposing  the  muscle  itself. 

Step  3. — Free  the  inner  edge  of  the  muscle  and  very  gently  retract  it  out- 
wards; the  forearm  being  sightly  flexed  to  relax  the  muscle.  This  exposes  the 
median  nerve. 

Step  4. — Mobilize  the  nerve  and  retract  it  outwards  or  inwards  as  may  be 
most  convenient.     This  exposes  the  artery  accompanied  by  its  two  veins. 

Step  5. — Open  the  arterial  sheath.     Ligate. 

Note. — During  the  operation  the  arm  must  be  abducted  and  supported 
by  the  elbow  or  forearm.  The  arm  itself  must  not  be  directly  supported,  as 
pressure  on  the  triceps  would  alter  anatomic  relations,  thus  making  exposure 
of  the  artery  difficult. 

Iliac  Arteries. — The  iliac  arteries,  especially  the  internal  vessel,  are  of 
so  much  and  varied  surgical  importance  that  they  deserve  full  consideration. 
The  usual  anatomical  works  do  not  cast  much  light  on  the  subject  from  the 
surgeon's   standpoint.     Quenu    and    Duval    ("Revue    de    Chirurgie,"    Nov., 


ILIACS. 


731 


1898)  study  the  anatomy  of  the  iliac  arteries  in  a  soul-satisfying  and  practical 
manner;  the  following  paragraphs  are  based  on  their  work. 

The  common  iliac  arteries  bifurcate  at  the  lower  level  of  the  fifth  lumbar 
veretbra,  i.  e.,  at  the  sacro-vertebral  angle,  i  3/8  inches  (3.5  c.)  from  the 
middle  line  (Fig.  826).  Near  their  origin  the  external  and  internal  iliac  arteries 
lie  close  together;  at  the  very  brim  of  the  true  pelvis  they  are  hardly  1/4  inch 


Fig.  826. — (Quenu  and  Duval.) 
M,  Median  line;  Hsl,  Int.  iliac;  Ur,  Ureter;  I.s.i.,  Sacro-iliac  joint;  D.  S.,  Brim  of 

pelvis. 


apart.  The  ureter  crosses  the  external  iliac  artery  slightly  outside  and  above 
the  internal  iliac  at  the  point  of  election  for  ligation  of  the  latter,  i.  e.,  a  little 
below  the  brim  of  the  pelvis.  The  ureter  is  fortunately  more  adherent  to  the 
peritoneum  than  to  the  subjacent  structures,  and  hence  is  easily  retracted  along 
with  the  peritoneum.  Such  are  the  relations  of  the  iliac  arteries  near  the  bi- 
furcation on  the  right  side;  on  the  lejt  side  the  surgical  anatomy  may  be  the 


732  LIGATION    OF   ARTERIES    IN    CONTINUITY. 

same  or  very  different,  according  to  the  arrangement  of  the  sigmoid  or  pelvic 
colon  and  its  meson. 

Let  us  consider  the  sigmoid  as  consisting  of  two  parts,  one  superior  (the 
colonic  sigmoid),  the  other  inferior  (the  rectal  sigmoid).  The  meson  belong- 
ing to  the  inferior  or  rectal  sigmoid  arises  always  in  the  middle  line  of  the  lumbo- 
sacral region.  The  meson  belonging  to  the  superior  or  colonic  sigmoid  has 
no  fixed  line  of  origin.  Its  lower  part  is  always  attached  along  with  the  meson 
of  the  rectal  sigmoid,  but  its  upper  part  may  be  attached  to  the  parietes  any- 
where between  the  spleen  (foetal  type)  and  the  pelvic  brim  (adult  type). 

The  point  of  junction  of  the  meson  of  the  two  portions  of  sigmoid  con- 
stitutes the  dome  of  the  intersigmoid  fossa,  and  on  the  floor  of  this  fossa  lie 
the  iliac  vessels  and  the  spot  where  the  internal  iliac  must  be  tied. 

The  length  of  the  sigmoid  varies  greatly  and  with  it  the  length  of  the  meson. 
If  the  sigmoid  is  long,  it  can  be  turned  upwards  with  the  whole  of  its  meson 
in  such  a  manner  that  the  intersigmoid  fossa  becomes  obliterated  and  the  iliac 
bifurcation  is  as  easily  exposed  as  on  the  right  side  of  the  body.  If  the  sig- 
moid is  short  its  meson  is  short  likewise;  by  turning  the  gut  upwards  its  meson 
becomes  folded  on  itself;  it  is  impossible  to  expose  the  point  of  union  of  the 
superior  and  inferior  portions  of  the  meson;  the  intersigmoid  fossa  is  a  true 
fossa  or  tunnel;  it  is  impossible  to  reach  the  bifurcation  of  the  iliac  artery  with- 
out going  through  the  meso-sigmoid.  This  second  arrangement  of  the  sig- 
moid is  the  rule. 

LIGATION  OF  THE  INTERNAL  ILIAC  ARTERY. 

(A)  On  the  Right  Side. — Step  i. — Place  the  patient  in  the  Trendelenburg 
position  (75°). 

Method  A. — Open  the  abdomen  by  a  vertical  incision  either  in  the  middle 
line  or  through  the  rectus  muscle  reaching  from  the  pubis  to  near  the  umbilicus. 
This  more  or  less  median  incision  is  the  best  if  the  vessels  on  both  sides  are  to 
be  tied. 

Method  B. — Make  a  vertical  incision  through  the  skin  and  anterior  layer 
of  the  rectus  sheath  near  the  outer  edge  of  the  rectus.  Either  split  the  rectus 
muscle  or  pull  it  towards  the  middle  line.  Incise  the  posterior  layer  of  rectus 
sheath  and  the  peritoneum  along  a  line  corresponding  to  the  skin  incision. 

Method  C. — Open  the  belly  by  the  gridiron  or  muscle-splitting  method 
devised  by  McBurney  for  appendicectomy. 

Especially  in  fat  patients,  method  A  is  the  best,  as  very  free  access  to  the 
vessels  is  of  great  value. 

Step  2. — Widely  retract  the  edges  of  the  abdominal  wound.  Push  the 
small  intestines  out  of  the  way  and  protect  them  with  pads.  Put  the  index 
finger  on  the  sacro-lumbar  promontory  in  the  middle  line.  Note  a  point 
I  3/8  inches  (3.5  c.)  to  the  right  side  at  the  same  level.  At  this  place  a  pul- 
sating prominence  is  visible  running  from  above  downwards  and  outwards. 


ILIACS. 


733 


This  pulsating  prominence  consists  of  the  common  and  external  iliac  arteries. 
Another  prominence  (the  ureter)  can  be  seen  crossing  it.  Run  the  finger 
down  the  common  iliac  artery  until  the  bifurcation  is  reached  when  pulsation 
will  be  felt  on  both  sides  of  instead  of  only  under  the  finger. 

Step  3. — Make  an  incision  i  1/2  inches  long  through  the  parietal  peritoneum, 
I  3/8  inches  to  the  right  of  the  middle  line,  parallel  to  the  iliac  vessels  and 
having  its  mid-point  opposite  the  lumbo-sacral  prominence.  Elevate  the 
edges  of  this  wound  by  blunt  dissection.  The  ureter  comes  away  with  the 
outer  edge  of  the  wound  and  is  thus  lifted  out  of  harm's  way.  At  the  upper 
angle  of  the  peritoneal  wound  lies  the  common  iliac,  at  the  centre  of  the  wound 
lies  the  bifurcation,  at  the  lower  angle  lie  the  external  and  internal  iliacs, 
side  by  side,  still  covered  by  a  sheath  of  fascia. 


Fig.  827. 


Step  4.— Incise  the  facial  sheath  secundem  artem;  denude  the  internal  iliac; 
pass  an  aneuryom  needle  from  without  inwards,  closely  hugging  the  artery  so 
as  to  avoid  injun,"^  to  the  external  iliac  vein,  and  apply  a  ligature  3/4  inch  from 
the  origin  of  the  vessel,  i.  e.,  at  a  point  a  very  little  below  the  brim  of  the  true 
pelvis.  Do  not  forget  that  the  internal  iliac  vein  lies  to  the  inner  side  of  the 
artery. 

(B)  On  the  Left  Side. — Step  i. — Put  in  Trendelenburg's  position.  Open 
the  abdomen  either  in  the  middle  line  or  on  the  lejt  side. 

Step  2. — (a)  If  the  sigmoid  is  long  and  provided  with  a  long  meson,  turn 
it  upwards.  This  obliterates  the  intersigmoid  fossa  and  leaves  the  vessels  as 
well  exposed  as  on  the  right  side.  Ligate  the  vessel  in  the  same  manner  as 
on  the  right  side. 

(b)  If  the  sigmoid  is  short  and  has  a  short  meson  it  cannot  be  turned  up 
so  as  to  expose  the  vessels.     Pull  the  sigmoid  downwards  so  as  to  spread  out  its 


734  LIGATION    OF   ARTERIES    IN    CONTINUITY. 

meson.  Note  the  position  of  the  mesenteric  vessels  in  the  meson,  they  must 
not  be  injured.  At  a  point  13/4  inches  from  the  middle  line  on  a  level  with 
the  lumbo-sacral  prominence  make  a  vertical  incision  through  the  meso- 
sigmoid,  carefully  avoiding  injury  to  any  of  its  vessels  (Fig.  827).  The  middle 
of  this  incision  corresponds  to  the  lumbo-sacral  prominence  and  its  lower 
end  must  not  approach  the  sigmoid  closer  than  i  1/4  inches,  lest  some  of  the 
arterial  loops  be  damaged.  If  the  meson  is  thick  and  much  infiltrated  with 
fat,  it  must  be  penetrated  slowly  by  blunt  dissection  to  avoid  injuring  the 
vessels. 

When  the  meso-sigmoid  is  penetrated  as  described,  the  floor  of  the  sig- 
moid fossa  is  reached  and  the  rest  of  the  operation  becomes  the  same  as  on 
the  right  side,  except  that  the  whole  work  must  be  accomplished  through  the 
rent  or  gap  made  in  the  meso-colon. 

LIGATION  OF  COMMON  ILIAC  ARTERY. 

The  common  iliac  artery  is  exposed  during  ligation  of  the  internal.  It 
is  unnecessary  to  describe  it  separately. 

EXTERNAL  ILIAC  ARTERY. 

(A)  Transperitoneal  Operation. — The  external  iliac  artery  may  be  ex- 
posed high  up  by  the  same  method  as  is  described  for  the  internal.  If  it  is 
desired  to  ligate  the  vessel  at  a  lower  level,  it  is  easy  to  expose  it  through  the 
abdomen  and  place  a  ligature  round  it  at  any  level. 

(B)  Extra-peritoneal  Operation.  Cooper's  Method. — Step  i. — From  a 
point  1 1/4  inches  external  to  the  pubic  spine  and  about  1/2  inch  above  Poupart's 
ligament  make  an  incision  parallel  to  the  ligament  to  a  point  opposite  the 
junction  of  the  middle  and  outer  thirds  of  the  ligament.  Continue  the  inci- 
sion in  a  curve  upwards  to  a  point  one  inch  above  the  internal  to  the  anterior 
superior  spine.  Be  sure  that  the  incision  is  large  enough.  Divide  the  ab- 
dominal wall  layer  by  layer  until  subperitoneal  fat  is  reached. 

Step  2. — With  fingers  and  gauze  push  the  peritoneum  (unopened)  upwards 
and  inwards  from  the  iliac  vessels.  When  the  vessels  are  exposed  keep  the 
wound  open  by  means  of  a  broad-bladed  retractor.  Trendelenburg's  pos- 
ture is  a  great  aid. 

Step  3. — The  external  iliac  artery  will  be  felt  running  along  the  brim  of 
the  pelvis  near  the  inner  end  of  the  wound.  Open  the  sheath  on  its  outer  side 
to  avoid  the  vein  which  lies  internal  to  the  artery. 

Demonstrate  and  pull  aside  the  genito-crural  nerve  which  lies  upon  or  near 
the  artery.     Pass  a  ligature  around  the  vessel  from  the  inner  side.     Tie. 

Step  4. — Remove  the  retractor.  Permit  the  peritoneum  to  fall  back  into 
place.  Suture  the  abdominal  wall,  layer  by  layer,  as  in  an  operation  for 
hernia. 

The  usual  site  for  ligation  is  about  i  1/2  inches  above  Poupart's  ligament. 


FEMORAL.  735 

As  a  means  of  temporary  hemostasis  a  temporary  ligature  or  tape  or  Crile's 
clamp  may  be  applied  to  any  of  the  iliac  vessels.  This  was  the  means  adopted 
by  Balch  to  control  the  circulation  when  he  performed  reconstructive  aneurys- 
morrhaphy  on  the  external  iliac  artery. 

LIGATION  OF  THE  COMMON  FEMORAL  ARTERY. 

The  common  femoral  may  be  ligated: 

(a)  As  a  preliminary  step  in  amputation  of  the  hip. 

(b)  For  hemorrhage  resulting  from  wounds  or  from  disease  in  Scarpa's 
triangle. 

(c)  For  aneurysm  of  the  superficial  femoral  high  up. 

Ligation  of  the  external  iliac  is  usually  preferable  for  many  reasons.  The 
operation  is  rarely  indicated.  The  writer  once  did  it  succesfully  for  hemorrhage 
after  a  high  amputation  of  the  thigh  where  the  bleeding-point  could  not  be 
found. 

The  dangers  of  gangrene  are  of  course  great.  In  cases  of  wounds  arte- 
rial suture  to  a  large  extent  takes  the  place  of  ligation.  The  common  femoral 
varies  in  length,  but  usually  extends  for  about  i  1/2  inches  below  Poupart's 
ligament.  The  line  of  the  femoral  (common  and  superficial)  stretches  from 
a  point  midway  between  the  anterior  superior  iliac  spine  and  the  middle  of 
the  pubis,  to  the  inner  margin  of  the  internal  condyle  of  the  femur  (adductor 
tubercle) . 

The  Operation. — Semiflex  the  hip  and  knee.  Abduct  and  rotate  the 
limb  somewhat  outwards.  Locate  the  artery  by  means  of  its  line  and  by  pal- 
pation. From  a  point  one  finger's  breadth  above  Poupart's  ligament  make 
a  2  1/2  inch  incision  downwards  along  the  line  of  the  artery.  Divide  the  skin 
and  superficial  fascia.  Retract  or  remove  any  glands,  retract  or  doubly 
ligate  and  divide  any  veins  which  may  overlie  the  vessel.  Feel  for  the  artery 
just  below  Poupart's  ligament  and  divide  the  deep  fascia  over  it.  Avoid  in- 
juring the  crural  branch  of  the  genito-crural  nerve  which  lies  over  the  artery. 
The  femoral  vein  being  on  the  inner  side  of  the  artery,  pass  the  ligature  from 
within  outwards.  Place  the  ligature  as  remote  as  possible  from  any  branches 
of  the  artery. 

Ligation  of  the  Superficial  Femoral  at  the  Site  of  Election — Apex 
of  Scarpa's  Triangle. 

The  operation  may  be  performed:  (a)  for  aneurysm  low  down  on  the 
artery;  (b)  for  hemorrhage  which  cannot  be  treated  by  more  direct  means; 
(c)  for  elephantiasis.  The  value  of  the  operation  in  elephantiasis  is  very 
doubtful. 

The  Operation. — Place  the  limb  as  for  ligation  of  the  common  femoral. 
The  line  of  the  artery  is  the  same  as  that  of  the  common.     From  a  point  about 


736  LIGATION    OF   ARTERIES    IX    CONTINUITY. 

2  1/2  inches  below  Pouparl's  ligament  make  a  three-inch  incision  downwards 
along  the  line  of  the  artery.  Divide  the  skin  and  superficial  fascia.  Retract 
and  divide,  between  ligatures,  any  superficial  veins  which  may  be  in  the  way. 
Split  the  deep  fascia  the  whole  length  of  the  wound.  Note  the  sartorius  crossing 
the  lower  part  of  the  wound  and  retract  it  outwards.  Find  the  artery  by  palpa- 
tion. The  long  saphenous  and  the  nerve  to  the  vastus  internus  are  in  contact 
with  the  artery;  avoid  them.  Open  the  sheath  of  the  artery  on  its  outer  side. 
The  vein  lies  to  the  inner  side  of,  and  behind  the  artery,  therefore  pass  the 
aneurysm  needle  from  within  outwards  and,  as  the  vein  has  often  been  damaged 
during  this  step,  be  most  careful  to  hug  the  artery  with  the  point  of  the  instru- 
ment. 

Jacobson  advises,  when  the  vein  is  injured,  to  make  pressure  on  the  vein 
at  the  lower  angle  of  the  wound  and  then  to  ligate  the  artery  at  a  point  either 
above  or  below  the  site  orginally  intended,  but  by  no  means  to  persist  in  attempt- 
ing to  finish  the  ligation  where  the  accident  occurred. 


CHAPTER  LXV. 

OPERATIONS  ON  VEINS. 

Most  of  the  operations  on  veins  are  so  similar  to  those  on  arteries  that  no 
special  description  of  them  is  necessary;  a  few,  however,  demand  more  particular 
^consideration. 

WOUNDS  IN  VEINS. 

When  a  small  vein  is  wounded,  the  best  treatment  is,  of  course,  to  stop  the 
bleeding  by  the  pressure  of  a  compress  or  forceps  or  by  the  application  of  a 
ligature.  When  a  larger  vein  is  completely  divided,  the  same  treatment  is 
proper.  Occasionally  a  vein  is  wounded  in  such  a  location  that  it  is  impossible 
to  apply  a  ligature;  in  this  case  the  bleeding  may  be  stanched  by  packing  the 
wound  with  gauze,  or  a  forceps  be  applied  and  left  in  place  for  from  twenty- 
four  to  forty-eight  hours  or  longer.  During  operation  in  various  localities, 
notably  the  neck  and  axilla,  a  large  vein  may  easily  be  wounded  by  accident 
or  design.  The  wound  may  be  picked  up  in  the  jaws  of  an  artery  forceps  and  a 
ligature  applied  laterally,  so  that  the  wound  is  closed,  while  circulation  con- 
tinues in  the  vein  whose  calibre  is  of  course  considerably  diminished. 

Schede  improved  on  the  above  treatment  by  closing  the  wound  with  sutures. 
He  used  thin  catgut  introduced  by  fine  Hagedorn  or,  better,  rounded  or  intes- 
tinal needles.  The  swelling  of  the  catgut  after  it  has  been  introduced  closes 
the  needle  punctures  and  prevents  escape  of  blood  through  them. 

The  method  of  suture  employed  is  the  ordinary  continuous  stitch,  including 
in  its  bite  all  the  coats  of  the  vein.  Bleeding  is  prevented  during  suturing  by 
finger  or  sponge  pressure  applied  above  and  below  the  wound,  or  by  forceps 
attached  close  to  the  wound  itself.  In  the  hands  of  Schede,  venous  suture  has 
never  failed  in  giving  satisfaction. 

In  removing  a  cancerous  kidney  Schede  threw  an  elastic  ligature  around  the 
pedicle  and  included  a  portion  of  the  vena  cava  in  the  ligature.  On  examina- 
tion of  the  pedicle  it  was  found  that  the  walls  of  all  the  vessels  were  diseased 
and  individual  ligation  was  impossible.  It  was  impossible  to  leave  the  elastic 
constrictor  in  situ.  "Under  careful  compression  of  the  vena  cava,  above  and 
below,  by  means  of  spongesticks,  the  ligature  was  removed.  Violent  hemor- 
rhage took  place  from  the  opposite  renal  vein.  The  wound  in  the  vena  cava 
was  quickly  closed  by  two  artery  forceps  so  placed  that  their  blades  surrounded 
the  wound  by  converging  from  above  and  below,  their  points  meeting  near  the 
middle  of  the  vena  cava.  Bleeding  ceased  and  the  remnants  of  the  tumor  could 
be  removed.     A  hole  about  3/4  inch  in  length  was  found  in  the  vena  cava.     This 

47  737 


738 


OPERATIONS    ON    VEINS. 


was  sutured.  The  forceps  were  removed.  There  was  no  bleeding."  The 
patient  lived  for  thirteen  days.  Postmortem,  narrowing  of  the  vena  cava  was 
found  at  the  site  of  operation,  the  wound  was  solidly  healed,  the  intima  was 
smooth,  and  there  was  not  the  slightest  trace  of  thrombosis.  Damar  Harrison 
has  had  a  similar  experience. 

I.  Intravenous  injection  of  salt  solution. 

The  solution  most  commonly  used  is  .75  per  cent,  or  .6  per  cent,  solution 
of  common  salt  in  sterile  water.  Usually  the  sterilization  is  accomplished  by 
boiling,  but  a  fatal  infection  due  to  bacillus  capsulatus  aerogenes  (this  organism 

resists  boiling  most  remarkably)  leads 
some  surgeons  to  insist  that  sterilization 
by  compressed  steam  be  the  rule. 

A  "rough  and  ready"  method  of 
preparing  the  salt  solution  is  to  add  a 
teaspoonful  of  salt  to  a  pint  of  water  and 
to  boil  the  solution.  The  water  used 
must  be  free  from  floating  particles. 
When  the  intravenous  injection  is  given 
because  of  shock  "adrenalin"  may  be 
added  to  the  salt  solution  (1:20,000). 

The  principal  indications  for  intra- 
venous infusion  of  salt  solution  are  shock 
and  hemorrhage.  Hypodermoclysis  and 
proctoklysis  have  largely  taken  the  place 
of  intravenous  infusion. 

Step  I. — Apply  a  bandage  around  the 
upper  arm  tightly  enough  to  cause  some 
distention  of  the  superficial  veins.  Choose  the  most  prominent  and  most 
convenient  vein,  usually  the  median  basilic.  Expose  the  vein  by  an  incision 
I  1/2  inches  in  length  along  the  long  axis  of  the  vein  or  obliquely  across  it.  Iso- 
late about  I  inch  of  the  vein. 

Step  2. — Surround  the  vein  with  two  catgut  ligatures  about  i  inch  apart. 
Tie  the  lower  ligature. 

Step  3. — Make  an  incision  from  below  upwards,  involving  about  half  the 
thickness  of  the  vein  in  such  fashion  that  proximal  side  of  the  wound  forms  a 
V-shaped  flap.  Catch  the  point  of  the  flaps  in  forceps  and  slide  under  it  into 
the  vein  the  end  of  the  blunt-pointed  cannula  (Fig.  828).  The  cannula  must 
be  directed  upwards.  Tie  the  catgut  ligature,  already  in  place  around  the 
cannula,  in  a  single  knot.  (An  ordinary  glass  pipette  such  as  is  sold  for  drop- 
ping solution  into  the  eye  or  for  filling  a  fountain  pen  makes  as  good  a  cannula 
as  any.)  Remove  the  constricting  bandage  from  the  arm.  The  cannula  must 
already  have  been  connected  with  a  funnel  (or  fountain  syringe)  filled  with  salt 
solution  at  a  temperature  of  ioo°-iio°  F.  As  the  cannula  is  being  introduced, 
solution  ought  to  be  flowing  from  it,  otherwise  air  may  enter  and  do  harm. 


TRANSFUSION    OF    BLOOD.  739 

Step  4. — Permit  the  warm  salt  solution  to  flow  into  the  vein.  Watch  the 
patient's  respiration  and  heart  action.  Any  sign  of  pulmonary  oedema  or 
cardiac  embarrassment  calls  for  immediate  stoppage  of  the  infusion.  From  a 
pint  to  a  quart  or  more  of  the  solution  may  be  introduced  in  the  course  of  thirty 
of  forty-five  minutes.  Remember  that  when  shock  is  very  profound  one  can 
easily  and  uselessly  introduce  vast  quantities  of  salt  solution  which  passes  into 
the  dilated  abdominal  veins  and  may  transude  into  the  intestines,  etc. 

Step  5. — As  soon  as  the  transfusion  is  finished,  remove  the  cannula.  Tie 
the  proximal  segment  of  vein.     Close  the  skin  wound. 

Of  course  any  superficial  vein,  e.  g.,  the  internal  saphenous  near  the  ankle, 
may  be  used  in  place  of  the  median  basilic. 

Direct  Transfusion  of  Blood. — Direct  transfusion  of  blood  was  more  or 
less  popular  many  years  ago,  but  was  given  up  in  favor  of  salt  solution  because 
of  technical  difficulties  and  because  of  the  belief  that  what  was  required  was 
not  blood,  but  a  bland,  isotonic  circulating  medium.  Advances  in  the  technic 
of  arterial  surgery  led  Crile  to  make  experimental  researches  in  direct  trans- 
fusion, and  he  has  found  it  to  possess  many  advantages  in  cases  of  shock  and 
of  hemorrhage.  Furthermore,  he  has  used  it  in  the  postoperative  treatment  of 
cancer,  hoping  thereby  to  raise  the  resisting  power  of  the  patient  to  the  un- 
known cause  of  cancer.  Bevan's  account  of  direct  transfusion  is  so  good  that 
it  is  reproduced  here  (Lexer-Bevan,  "General  Surgery,"  p.  1008). 

"Transfusion  Cannula. — The  first  model  for  the  transfusion  cannula  was 
suggested  to  Crile  by  Dr.  Mixter  in  December,  1906.  Dr.  Mixter  designed  and 
constructed  a  splendid  model  made  of  two  parts.  Payr's  magnesium  tube 
gave  some  good  suggestions  as  well.  The  cannula  now  in  use  answers  the 
purpose  splendidly,  and  was  developed  in  its  present  form  after  more  than 
twenty  various  models  were  made. 

"Management  and  Technic  of  Operation. — A  suitable  donor  is  usually 
readily  obtained.  We  use  both  men  and  women.  In  cases  in  which  no  immedi- 
ate emergency  exists  the  most  suitable  subject  is  singled  out  from  among  relatives 
and  friends.  He  is  approached  tactfully,  the  most  opportune  time  being  just  after 
he  has  left  the  bedside  of  the  patient.  The  gravity  of  ihe  patient's  condition  and 
the  only  means  of  relief  are  carefully  detailed,  the  painlessness  of  the  procedure 
to  both  donor  and  recipient  being  assured.  Almost  invariably  a  voluntary 
suggestion  to  serve  as  donor  results.  Indeed,  frequently  an  entire  family 
and  friends  have  offered  their  ser\dces. 

"  Our  only  difficulty  thus  far  has  arisen  among  ward  patients  who  have  certain 
amount  of  distrust  of  surgeons  and  hospitals.  Among  these  patients,  however, 
I  have  experienced  but  one  refusal,  that  being  in  the  case  of  foreign  parents  of  a 
child  of  nine,  whose  legs  had  been  crushed,  the  argument  being  that  the  child 
was  not  worth  saving.  In  two  other  instances  the  donors  were  hired.  In  these 
cases  the  commerical  attitude  was  apparent  and  the  donors  were  not  as  tractable 
as  those  who  responded  to  the  appeal  of  sentiment.  A  careful  investigation  as 
to  the  health  of  the  donor,  both  as  to  whether  or  not  it  is  advisable  to  remove 


740  OPERATIONS    ON    VEINS. 

blood  and  whether  or  not  there  is  any  disease  which  might  be  transmitted, 
is  always  made. 

''  When  there  is  time  haemolysis  observations  are  obtained  from  the  proposed 
donor  and  the  recipient.  This  test  requires  about  twenty-four  hours.  By 
making  the  haemolysis  test  of  the  proposed  donor  and  of  the  recipient  various 
blood  reactions  may  be  obviated.  Agglutination  may,  I  think,  with  safety 
be  disregarded. 

"The  operating-room  should  be  equipped  with  two  tables,  preferably  of  the 
kind  which  permits  of  a  change  of  posture  from  head-up  to  head-down.  The 
patients  are  given  pillows  in  order  to  be  made  as  comfortable  as  possible,  and 
are  so  arranged  that  the  left  arm  of  each  may  be  used.  The  donor  should  be 
placed  on  the  table  so  that,  if  necessary,  the  Trendelenburg  position  may  be 
utilized.  The  recipient,  if  both  postures  are  not  available  should  be  arranged 
so  that  the  reverse  Trendelenburg  may  be  given.  This  permits  the  better 
rnanagement  of  a  possible  dilatation  of  the  heart  of  the  recipient  and  of  a  cere- 
bral anaemia  of  the  donor.  I  have  found  that  it  is  a  great  aid  to  have  a  trained 
operative  staff,  so  that  the  many  details  may  be  performed  without  delay  and 
without  speaking.  Two  small  movable  tables,  the  height  of  the  operating- 
tables,  are  most  convenient  for  supporting  the  arms  and  the  instruments  during 
the  dissection.  One  of  these  tables  will  support  both  arms  during  the  process 
of  making  the  anastomosis  and  during  the  remainder  of  the  transfusion. 
On  either  side  of  this  table  and  between  the  two  operating-tables  a  stool 
is  placed,  which  provides  a  comfortable  and  a  steady  position  for  the 
operator  and  his  first  assistant  vis-a-vis.  From  the  beginning  until  the  end 
not  an  unnecessary  word  is  spoken.  Both  the  donor  and  the  recipient,  unless 
contraindicated,  are  given  a  preliminary  hypodermic  of  1/4  grain  of  morphin 
twenty  to  thirty  minutes  prior  to  their  entrance  to  the  operating-room.  The 
patients  are  assured  that  they  will  experience  no  pain,  save  the  first  needle 
prick.  In  order  that  they  may  not  obtain  a  glimpse  of  the  operating-room  or  of 
their  environment,  both  patients  are  told  that,  owing  to  the  bright  light,  wet 
towels  will  cover  their  eyes,  thus  preventing  a  possible  headache.  They  are 
warned  of  the  first  needle  prick,  and  are  told  that  cocain  will  now  be  administered, 
that  it  will  require  twenty  or  thirty  minutes  to  take  effect,  and  that  in  the  mean- 
time it  will  be  necessary  to  massage,  to  prick,  and  to  pull  the  tissues,  but  that 
the  procedure  is  painless.  One  nurse  is  detailed  to  relieve  the  monotony  of 
waiting  by  substituting  fresh  towels,  bathing  the  brow,  administering  water  if 
desired,  and  giving  helpful  attention. 

"Local  anaesthesia  is  maintained  by  infiltration  of  i/io  per  cent,  solution  of 
cocain  with  a  few  drops  of  adrenalin,  first  in  the  skin  proper,  and  then  in  the 
neighborhood  of  the  vessels,  after  which  firm  pressure  for  thorough  dissemi- 
nation is  applied.  When  carefully  performed  there  is  absolutely  no  pain  in  any 
part  of  the  procedure  until  the  suture  of  the  skin  at  the  close  of  the  transfusion, 
at  which  time  the  effect  of  the  cocain  has  disappeared. 

"  In  the  dissection  I  have  found  it  an  advantage  to  use  minute  instruments, 


TRANSFUSION    OF    BLOOD.  741 

selecting  from  among  the  armamentarium  of  oculists  and  watchmakers.  Mos- 
quito forceps  arc  used  to  catch  every  vessel  that  sheds  even  a  drop  of  blood, 
keeping  the  field  not  only  clean  but  translucent.  The  donor's  radial  artery 
is  isolated  a  distance  of  about  3  cm.  At  the  point  of  election  there  are  a  number 
of  small  branches  which  should  be  carefully  isolated  and  tied,  otherwise  an 
obscuring  hemorrhage  may  occur.  The  small  nerve  branches  and  the  venae 
Somites  are  pushed  aside.  The  artery  is  then  tied  at  its  distal  end,  and  at  the 
proximal  a  screw  clamp  gently  closes  its  lumen.  The  artery  is  then  divided 
with  a  sharp  scissors,  the  adventitia  is  drawn  well  over  its  end  and  snipped  off 
closely.  This  leaves  a  clean  open  end  of  the  vessel,  but  the  manipulation  and 
exposure  to  the  air  causes  such  sharp  contractions  that  for  a  time  its  lumen 
IS  obliterated.  This  is  easily  overcome  by  inserting  into  the  lumen  a  mosquito 
forceps,  covered  with  vaseline,  then  gently  opening  the  blades.  This  over- 
stretching of  the  artery's  lumen  prevents  recontraction.  Any 
superficial  vein  that  seems  neither  too  large  nor  too  small  is  like- 
wise exposed,  isolated,  ligated  at  its  distal  end,  closed  by  a  screw 
clamp  at  its  proximal  part,  divided  near  the  ligature  with  sharp  j.^^,  j^^ 
scissors,  and  its  adventitia  drawn  well  out  over  the  end  and 
snipped  off  closely,  thus  leaving  a  free  manipulable  end.  The  tables  of  the 
donor  and  of  the  recipient  are  approximated  with  their  heads  in  opposite  direc- 
tions, so  that  the  vessels  may  be  approximated  more  readily  and  the  stream 
may  be  transferred  in  nearly  a  straight  line.  The  vessels  are  now 
compared  with  the  various  sizes  of  the  transfusion  cannulae  and  a 
suitable  one  selected.  (Fig.  829,  Crile's  Cannula).  Then  with  mosquito  for- 
ceps the  handle  of  the  cannula  is  grasped  and  the  cannula  dipped  in  sterilized 
vaseline  or  oil.  The  vein  is  next  pushed  through  the  lumen.  With  oculist's 
small,  self-locking  forceps  or  mosquito  hemostats  the  margin  of  the  vein 
is  grasped,  turning  it  back  as  a  cuff  over  the  outside  of  the  cannula, 
and  a  fine  ligature  of  linen  tied  firmly  around  the  cuff  in  the  second 
groove,  the  ends  of  the  ligature  being  cut  off.  With  one  hand  the  cannula 
is  steadied  by  means  of  the  hemostat,  and  with  small,  locking  thumb 
forceps  or  mosquito  hemostats  the  assistant  and  operator  grasp  the  end 
of  the  artery  at  three  equidistant  points  and  draw  it  over  the  venous  cuflf 
and  cannula,  tying  it  snugly  with  a  small  linen  ligature  in  the  first  groove, 
thus  completing  the  anastomosis.  The  screw  clamp  is  then  removed  first  from 
the  vein,  then  from  the  artery,  and  the  flow  tested.  At  first,  owing  to  the  great 
contraction  of  the  artery,  but  little  blood  flows  across,  but  by  liberal  application 
of  warm  salt  solution  the  vessel  soon  dilates  and  the  stream  grows  larger, 
reaching  its  maximum  in  about  ten  minutes.  It  is  most  important  not  to  bruise 
the  vessels  or  to  break  the  intima.  In  every  instance  in  the  51  clinical  cases  the 
technic  was  entirely  successful. 

''Conclusions. — The  principal  danger  of  transfusion,  now  that  the  technic 
is  prefected,  is  haemolysis.  This  apparently  occurs  only  in  disease.  The 
dangers  of  haemolysis  may  be  prevented  by  determining  before  the  operation  is 


742 


OPERATIONS    ON    VEINS. 


undertaken    whether    the  blood  of  the  donor  is  haemolytic  for  that  of  the 
recipient. 

"  Sufficient  facts  have  been  determined  by  laboratory  experiments  and  clinical 
observations  to  justify  the  following  conclusions:  Transfusion,  when  properly 
safeguarded,  may  be  safely  done.     In  pernicious   anaemia,  toxaemia,  certain 


Fig.  830. — {Hepburn.) 

drug  poisoning,  leukaemia,  acute  hyperthyroidism,  and  uraemia,  it  has  been  of  no 
value.  In  tuberculosis,  carcinoma,  and  chronic  infections  it  is  of  doubtful  or 
at  best  of  little  value.  In  human  sarcoma  there  is  some  evidence  of  value, 
through  not  yet  proved.  In  pathological  hemorrhage  it  is  of  marked  value.  In 
suitable  cases  it  seems  to  be  almost  a  specific  in  the  prevention  and  treatment 


Fig. ^83 1. — {Hepburn.) 


Fig.  832. — {Hepburn.) 


of  shock.     In  acute  hemorrhage  in  animals  it  is  specific;  in  human  beings  it 
has  proved  most  valuable." 

Hepburn  ("Annals  of  Surg.,"  Jan.,  1909)  modifies  Crile's  cannula  so  as  to 
render  the  necessary  manipulation  less  difficult.  The  flange  of  the  cannula  is 
provided  with  four  perforations  (Fig.  830).  By  means  of  four  threads  the  vein 
is  pulled  through  the  cannula  (Fig.  830) ;  the  threads  are  passed  through  the 


TRANSFUSION    OF    BLOOD. 


743 


perforations  in  the  flange  (Fig.  831)  and  by  traction  on  them  it  becomes  easy 
to  evert  the  vein  over  the  cannula  (Fig.  832)  where  it  can  be  fixed  by  a  ligature. 
In  similar  fashion  provide  the  open  end  of  the  artery  with  four  thread  tractors; 
pass  the  threads  through  the  perforations  in  the  flange  and  by  traction  on  the 
threads  pull  the  artery  over  the  cannula.  With  a  ligature  tie  the  artery  to  the 
cannula  (Figs.  833  and  834). 

1/ 


Fig.  833. — {Hepburn.) 


DIRECT  VEIN-TO-VEIN  TRANSFUSION. 

Dorrance  and  Ginsburg  ("Jour.  A.  M.  A.,"  Aug.  13,  1910)  advise  direct 
"vein-to-vein"  transfusion.  A.  M.  Fauntleroy  ("Med.  Record,"  Sept.  3,  1910) 
has  used  Brewer's  tubes  slightly  modified  for  the  same  purpose.     The  method 


Fig.  834. — {Hepburn.) 

has  this  great  advantage  over  "artery-to-vein"  transfusion  that  it  is  exceedingly 
simple  and  the  special  apparatus  (the  tubes)  can  be  quickly  made  from  inex- 
pensive materials. 

Preparation  of  Tubes. — Take  a  segment  of  thin  glass  tube  about  3  inches 
long  and  1/8  inch  inside  diameter.     Cut  the  ends  square.     Heat  the  ends  and 


744 


OPERATIONS    ON   VEINS. 


when  hot  push  into  them  a  piece  of  pointed  metal  (a  sharp-pointed  wire  nail 
will  do).  This  presses  outwards  the  edge  of  the  glass  and  makes  a  small  flange. 
Heat  the  tubing  and  bend  it  into  the  shape  of  a  wide  U  or  of  an  S.  Both 
shapes  are  useful.  The  S  tube  is  necessary  during  arm-to-arm  transfusion 
when  the  arms  of  the  donor  and  recipient  are  lying  side  by  side  with  the  hands 
pointed  in  the  same  direction  (Fig.  835 ) ;  the  U  tube  is  necessary  when  the  donor's 
hand  is  pointed  towards  the  shoulder  of  the  recipient.  Sterilize  the  tubes  by 
boiling;  drop  them  in  melted  parafiin;  pick  them  out  with  sterile  forceps  and 
shake  all  excess  of  paraflan  out  of  their  lumen;  lay  in  sterile  gauze  to  cool  and 
then  wipe  away  the  parafiin  on  their  outer  surfaces. 

The  Operation. — If  the  median-cephalic  or  median  basilic  veins  are  chosen 
for  the  operation  proceed  as  follows: 


Fig.  835. — {Fdiintleroy.) 


Surround  the  arm  of  the  recipient,  above  the  site  of  operation,  with  a 
bandage  sufhciently  t  ghtly  to  make  the  peripheral  veins  prominent.  Expose 
the  chosen  veins  for  about  one  inch.  Pass  two  ligatures  round  the  vein,  one 
in  the  upper  and  one  in  the  lower  angle  of  the  wound.  Tie  the  /ower  ligature. 
Remove  the  constricting  bandage.  Similarly  expose  and  pass  ligatures  round 
the  vein  of  the  donor  and  tie  the  upper  ligature.  Temporarily  occlude  the  lower 
segment  of  vein  by  Crile's  clamp  or  its  equivalent.  Divide  or  open  the  vein 
far  enough  above  the  clamp  to  permit  the  introduction  of  one  end  of  the  glass 
tube.  Introduce  the  tube  into  the  lower  segment  of  vein,  and  tie  the  lower 
ligature,  thus  holding  the  flanged  end  of  the  tube  in  the  vein.  Bring  the  arm  of 
the  donor  alongside  that  of  the  recipient;  open  the  vein  of  the  recipient.  Bring 
the  free  end  of  the  tube  (already  connected  with  the  donor)  close  to  the  recipi- 
ent's vein;  release  the  Crile's  clamp  and  let  the  blood  flow  from  the  donor  and 
escape  through  the  glass  tube.  Insert  the  free  end  of  the  glass  tube  into  the 
vein  of  the  recipient  and  fasten  it  by  tying  the  ligature  already  in  place.  The 
bandage  which  constricts  the  arm  of  the  donor  is  left  in  place  so  as  to  keep  so 
much  pressure  in  the  veins  that  the  blood  will  flow  freely  from  donor  to 
recipient;  the  bandage  must  not  of  course  interfere  with  the  arterial  circulation. 

When  the  transfusion  is  completed,  remove  the  tube,  ligate  the  open  veins 
and  close  the  wound. 

Infective  Phlebitis. — For  many  years  it  has  been  customary  to  ligate  the 
internal  jugular  vein  to  prevent  dissemination  of  infection  in  cases  of  sigmoid 


VARICOSE    VEINS.  745 

sinus  thrombosis.  The  same  treatment  is  applicable  in  acute  thrombophlebitis 
in  other  localities.  The  principle  of  the  operation  is  to  ligate  the  vein  at  a 
point  above  the  thrombus  and  then  to  open  and  clean  out  the  vein  where  it  is 
diseased,  or  still  better  to  excise  the  diseasd  segment.  Trendelenburg  records 
a  case  of  general  chronic  puerperal  infection  which  recovered  after  double 
ligation  of  the  inflamed  and  thrombosed  right  hypogastric  (internal  iliac)  and 
spermatic  veins.  The  details  of  the  operation  required  are  practically  the 
same  as  for  similar  procedures  on  the  arteries. 

Varicose  Veins. — The  excuse  for  the  superficial  veins  of  the  leg  becoming 
varicose  is  that  being  outside  the  deep  fascia  they  are  poorly  supported. 

The  principle  of  treatment  of  varicose  veins  is  the  transference  of  the 
venous  circulation  from  the  superficial  to  the  deep  veins,  but  before  attempting 
to  do  this  it  must  be  shown  that  there  is  neither  thrombosis  of  the  deep  veins  nor 
marked  obstruction  to  the  return  of  blood  through  them.  It  must  be  remembered 
that  varicosed  superficial  veins  may  be  nature's  means  of  dodging  obstruction  of 
the  deep  vessels. 

Mayo,  in  doubtful  cases,  applies  an  elastic  support  to  the  limb  for  a  week; 
if  this  gives  comfort  it  is  fairly  evident  that  the  deep  vessels  are  capable  of  doing 
their  duty. 

Trendelenburg,  struck  by  the  fact  that  regurgitation  of  blood  takes  place 
from  the  deep  femoral  into  the  long  saphenous  vein,  doubly  ligated  and  divided 
the  latter  close  to  the  saphenous  opening.  The  operation  is  a  good  one  when 
the  condition  is  due  to  regurgitation.  The  test  for  regurgitation  is  as  follows: 
(i)  Elevate  the  limb  until  the  veins  empty  themselves.  (2)  Make  pressure  over 
the  vein  near  the  saphenous  opening.  If  the  superficial  veins  now  quickly 
become  prominent  Trendelenburg's  operation  will  probably  be  inefficient.  (3) 
The  veins  have  not  become  prominent;  still  keeping  up  pressure  at  the 
saphenous  opening,  let  the  limb  hang  down.  Remove  the  pressure.  If  a 
column  of  blood  passes  doivn  the  vein,  Trendelenburg's  method  will  probably  , 
be  efficient. 

Trendelenburg's  Operation. — Local  anaesthesia  usually  suffices.  Place 
a  rubber  band  around  the  upper  part  of  the  thigh  sufficiently  tightly  to  cause 
dilatation  of  the  superficial  veins.  This  precaution  may  be  dispensed  with  if 
desired.  At  the  junction  of  the  upper  and  middle  thirds  of  the  thigh  make  a 
longitudinal  incision  about  one  and  one-half  inches  in  length  along  the  course  of 
the  vein.  A  transverse  incision  is  preferable  in  fat  patients.  Expose  and 
isolate  the  vein;  ligate  it  with  catgut  at  the  upper  and  lower  ends  of  the  wound; 
excise  the  portion  lying  between  the  ligatures.  Close  the  wound  with  sutures. 
Dress.  Repeat  the  above  procedure  at  a  point  immediately  below  and  one 
immediately  above  the  internal  condyle.  Keep  the  limb  at  rest  for  from  two 
to  three  weeks.  When  painful  varicose  tumors  are  present,  the  author  always 
supplements  the  Trendelenburg  operation  by  excising  such. 

Cecca's  Operation. — In  certain  uncomplicated  cases  of  varicose  veins  where 
the  long  saphenous  presents  no  old  secondary  lesions  and  where  its  branches 


746  OPERATIONS    ON    VEINS. 

are  not  extensively  dilated,  R.  Cecca  (Ref.  "Journal  de  Chir.,"  i,  No.  9)  suggest^ 
giving  support  to  the  diseased  vessel  by  transplanting  it  under  the  fascia.  The 
operation  consists  of  exposure  of  the  vein  by  a  long  incision — incision  of  the 
fascia — insertion  of  the  vein  through  the  long  wound  in  the  fascia — suture  of 
the  fascia  over  the  vein — closure  of  the  skin  v^ound. 

Phelp's  Operation.— Multiple  subcutaneous  ligation.  Pass  a  handled 
needle  with  its  eye  near  the  point,  through  the  skin,  behind  the  vein,  and  out 
though  the  skin  on  the  opposite  side  of  the  vein.  Thread  the  needle  with  stout 
silk;  withdraw  the  needle  and  unthread  it.  Through  the  same  puncture  rein- 
troduce the  needle;  pass  it  iw front  of  the  vein  and  out  through  the  skin  puncture 
on  the  opposite  side  of  the  vein  made  in  the  previous  movement.  Thread  the 
free  end  of  the  silk  ligature  in  the  needle  and  withdraw  the  needle.  By  the 
above  means  a  silk  ligature  has  been  made  to  surround  the  vein,  and  its  ends 
emerge  through  the  same  puncture  in  the  skin.  Tie  the  ligature  tightly.  Re- 
peat the  operation  at  about  thirty  or  forty  places.  Apply  dressings  and  pre 
scribe  rest  in  bed. 

Mayo's  Operation. — C.  H.  Mayo  excises  the  long  saphenous  vein  as  follows: 
Expose  and  isolate  the  vein  near  the  saphenous  opening.  Divide  the  vein 
between  ligatures.     Seize  the  peripheral  portion  of  the  vein  with  a  hemostat. 

Pass  the  end  of  the  vein  through  the  loop  of  Mayo's  dissector  (Fig.  836  c). 
Guided  by  the  vein  push  the  dissector  under  the  skin  down  to  a  point  near  the 
knee;  cut  through  the  skin  over  the  end  of  the  dissector;  clamp  the  vein,  pull 
it  out  through  the  woimd,  ligate  and  excise  the  loose  portion.  If  the  dissector 
is  obstructed  in  its  work  by  adhesions  around  the  vein,  pass  the  closed  forceps 
(Fig.  836  b)  alongside  it,  and  when  the  adhesions  are  reached  open  the  blades 
of  the  forceps  slightly;  this  usually  overcomes  the  trouble  and  the  dissector  can 
complete  the  work.  In  the  same  manner  remove,  subcutaneously,  as  many 
other  veins  as  may  be  necessary.  The  dissection  should  be  from  above  down- 
wards to  avoid  the  danger  of  detaching  thrombi  and  throwing  them  into  the 
circulation. 

Removal  by  Inversion. — The  following  description  is  of  the  operation  as 
performed  by  Mamourian ;  elevate  the  limb.  Expose  the  long  saphenous  vein  near 
the  saphenous  opening.  Divide  the  vein  between  clamps.  Ligate  the  proximal 
stump.  Apply  traction  to  the  distal  stump  and  thus  make  the  vein  prominent 
along  its  course  as  far  as  the  knee.  Expose  the  vein  by  a  small  incision  on  the 
inner  aspect  of  the  knee.  Divide  the  vein  between  two  clamps.  Ligate  the 
distal  segment.  Remove  the  clamp  on  the  proximal  segment  and  pass  a  long 
probe,  eye  first,  up  the  lumen  of  the  vein  until  it  comes  out  of  the  first  incision 
from  which  the  clamp  applied  early  in  the  operation,  has  been  removed.  With 
a  needle  pass  a  suture  through  all  the  coats  of  the  segment  of  vein  to  be  removed 
at  its  upper  end.  This  suture  must  penetrate  the  vein  twice  and  pass  through 
the  eye  of  the  probe.  Tie  the  suture  firmly.  Pull  on  the  distal  end  of  the 
probe  and  so  extract  the  vein  at  the  same  time  turning  it  outside  in. 

Marmourian    writes    ("Brit.   Med.    Joum.,"   July    16,    1910):     "All    the 


VARICOSE    VEINS. 


747 


prominent  veins  of  the  leg  can  be  dealt  with  in  similar  fashion.  If  they  are 
very  tortuous,  a  gum-elastic  catheter  should  be  used  instead  of  the  probe.  The 
method  is  not  applicable  to  cases  of  general  or  cirsoid  varicosities." 

Babcock's  Operation.  ("  Joum.  A.  M.  A.,"  July  i6,  1910). — Babcockhas 
improved  an  operation  which  he  published  in  1907.  A  special  instrument 
required  is  a  long,  pliable  probe  with  a  small  acorn  tip  at  one  end  capable  of 
passing  through  the  lumen  of  the  vein  to  be  removed;  at  the  other  end  is  a  larger 


Fig.  836. — (Mayo.) 


acorn  tip,  the  shaft  surface  of  the  acorn  being  so  cuffed  as  to  catch  the  wall 
of  the  vein  and  prevent  its  inversion  and  slipping  over  the  end  of  the 
instrument. 

Expose  the  vein  either  at  the  upper  or  lower  end  of  the  segment  to  be  re- 
moved (preferably  the  upper  end,  to  obviate  dangers  of  embolism  (J.  F.  B.). 
Grasp  the  vein  with  a  hemostat.  Incise  the  vein  and  introduce  the  smaller 
end  of  the  probe.  Pass  the  probe  along  the  inside  of  the  vein  for  the  required 
distance  or  until  some  obstruction  is  encountered.  With  strong  silk  tie  the  vein 
to  the  shaft  of  tlie  probe  close  to  its  larger  acorn  end.  Divide  the  vein  between 
the  hemostat  and  the  probe.  Replace  the  hemostat  by  a  ligature.  Incise  the  soft 
parts  including  the  wall  of  the  vein  over  the  smaller  end  of  the  probe  which  may 
be  felt  or  seen.     Grasp  the  small  end  of  the  probe  and  pull  it  out  of  the  wound  by 


748 


OPERATIONS    ON   VEINS. 


firm  traction  combined  with  a  series  of  short  jerks.  The  vein  comes  away 
pleated  firmly  in  a  small  fusiform  mass  against  the  concavity  of  the  larger  bulb 
of  the  instrument.  The  procedure  may  be  repeated  on  other  varicose  veins  as 
required. 

Schede's  Operation. — In  the  upper  third  of  the  leg  make  an  incision  com- 
pletely round  the  limb,  dividing  all  the  tissues  down  to  the  deep  fascia.  As 
the  cut  is  being  made  doubly  ligate  and  divide  all  the  veins. 

Von  Wenzel's  operation  is  the  same  as  Schede's  plus  a  similar  circular 
incision  at  the  junction  of  the  middle  and  lower  thirds  of  the  thigh. 


Fig.  2,T,-j.~{Friedel.) 


Friedel's  Operation  ("Archiv  fiir  klin.  Chir.,"  Ixxxvi,  p.  143).— When 
the  veins  in  the  leg  are  not  only  increased  in  size  but  in  numbers  and  repeated 
attacks  of  inflammation  have  so  imbedded  them  in  scar  tissue  that  excision  is 
impossible,  Friedel's  operation  gives  promise  of  value.  Much  oedema  is  usually 
present,  giving  the  limb  an  appearance  of  elephantiasis — ulcers  are  almost 
always  evident  and  the  question  of  amputation  arises. 

The  Operation. — Step  i. — Doubly  ligate  and  divide  the  long  saphenous 
high  up  in  the  thigh. 

Step  2. — With  a  knife  mark  a  spiral  line  running  round  and  round  the  leg 
from  a  point  below  the  disease  to  a  point  well  above  it.  The  closer  together 
the  rings  of  the  spiral  lie,  the  oftener  will  the  veins  be  divided  and  the  greater  the 
probability  of  cure.     When  ulcers  are  present  the  spiral  should  surround  the  leg 


VARICOSE   \'EIXS.  749 

both  above  and  below  them.     Necrosis  of  the  skin  has  not  developed  as  a  result 
of  the  spirals  being  close  together. 

Step  3. — Guided  by  the  marks  on  the  skin,  make  an  incision  down  to  the 

deep  fascia.     As  this  cut  is  made  inch  by  inch,  A\ddely  retract  . 

the  edges  of  the  woimd  and  ligate  or  throw  a  stitch  around  I      ^    / 

each  vein  which  does  not  stop  bleeding  under  simple  tamponade.  /           / 

Continue  the  cut  until  it  follows  the  entire  length  of  the  spiral  I             ( 

traced. on  the  skin  in  Step  2  (Fig.  837).  <^.....^^\ 

Where  an  ulcer  exists  join  the  spirals  above  and  below  it  /^^^^T...   1 

by  two  vertical  incisions  so  as  to  cut  off  the  veins  coming  from  f^^^^Zsi*--/ 

the  ulcer  (Fig.  838).  f^^SW 

Step  4. — Pack  the  whole  length  of  the  wound  so  that  it  must  V^*7 

heal  by  granulation.      During  the  after-treatment  destroy  all  k^TTj 

superficial  granulations  which  might  fill  up  the  wound  before  J>-^^^ 

epidermization  takes  place.     It  is  of  importance  to  have  the  ^    ^    \ 

epithelium  spread  from  the  skin  down  into  the  depth  of  the        ^ ^ 

wound  so  that  a  ver}'  deep  permanent  spiral  gutter  is  formed  Fig.  838. 
giving  the  leg  somewhat  the  appearance  of  rolled  beef. 

To  the  author  it  seems  the  Friedel's  operation  has  a  distinct  field  of 
usefulness. 

RESULT  OF  OPERATIONS  FOR  VARICOSE  VEINS. 

Jeannel  (French  Congress  of  Surgery,  19 10)  remarks  that  some  surgeons 
class  as  cured  cases  in  which  there  may  be  persistence  of  varicosities  if  they  are 
less  voluminous  or  less  painful  and  disabling  than  before  operation;  other  sur- 
geons only  class  as  cured  patients  in  whom  the  varices  no  longer  exist  and  who 
have  restored  to  them  a  healthy,  vigorous,  painless  limb.  In  the  following 
tables  taken  from  Jeannel  the  latter  conception  of  the  word  "cured"  is  adopted. 

A.  Results  of  operations  directed  against  the  superficial  reflux  of  blood. 

(a)  Trendelenburg's  operation  and  its  variants. 

Six  hundred  and  ninety-seven  limbs  operated  on  and  examined  after  the 
lapse  of  from  two  months  to  twelve  years. 

393  cured 56  per  cent. 

90  doubtful    13  per  cent. 

214  failures 31  per  cent.  44  per  cent. 

(6)  Resection  of  whole  femoral  part  of  the  internal  saphenous  vein. 
Twenty-three  limbs  operated  on  and  examined  after  from  two  months  to 
seven  years. 

12  cured 52  per  cent. 

3  doubtful 22  per  cent. 

6  failures 26  per  cent.  48  per  cent. 


750  OPERATIONS    ON    VEINS. 

B.  Results  of  operations  directed  against  the  deep  reflux  of  blood. 

(a)  Excision  of  isolated  varices. 
Seventy  limbs  operated  on. 

52  cured 74  per  cent. 

5  doubtful 4  per  cent. 

15  failures 22  per  cent.  26  per  cent. 

(b)  Resection  of  all  or  most  of  the  internal  saphenous  or  of  the  external 
saphenous  vein. 

Fifty-seven  limbs  operated  on  and  examined  after  from  two  months  to 
eight  years. 

26  cured 46  per  cent. 

12  doubtful 19  per  cent. 

20  failures 35  per  cent.  54  per  cent. 

C.  Results  of  operations  directed  against  both  superficial  and  deep  reflux 
of  blood. 

(a)  Trendelenburg's  operation  with  its  variants  plus  multiple  ligations 
and  resections  both  in  the  thigh  and  leg. 

Ninety-five  limbs  operated  on  and  examined  after  from  one  month  to 
fourteen  years. 

57  cured 60  per  cent. 

21  doubtful 22  per  cent. 

1 7  failures 18  per  cent.  40  per  cent. 

(b)  Complete  saphenectomy. 

Seventy-seven  limbs  operated  on  and  examined  after  periods  of  from  a 
few  months  to  seven  years. 

73  cured 95  per  cent. 

4  failures 5  per  cent. 

These  tables  of  Jeannel's  show  the  importance  of  recognizing  in  any  in- 
dividual case  whether  the  trouble  is  purely  due  to  superficial  reflux  of  blood 
when  Trendelenburg's  operation  or  one  of  its  variants  ought  to  suffice;  or 
whether  the  trouble  is  due  to  a  deep  reflux  of  blood  or  to  both  superficial  and 
deep  reflux  when  one  of  the  more  radical  operations  will  be  necessary. 

LYMPHANGIOPLASTY.     (HANDLEY'S  OPERATION.) 

In  about  16  per  cent,  of  cases  of  breast  cancer  difl^usion  of  the  disease 
and  perilymphangitis  causes  obstruction  of  the  lymphatics  about  the  shoulder 
which  leads  to  oedema  of  the  arm.  This  oedema  causes  intense  suffering  and 
disability  for  which  opiates  or  amputation  were  the  only  relief  imtil  Handley 
devised  his  simple  operation. 

The  operation  of  lymphangioplasty  has  no  effect  on  the  carcinoma ;  it  merely 


LYMPHANGIOPLASTY. 


751 


provides  new  means  for  the  lymphatic  drainage  of  the  arm.  Handley's  results 
have  been  most  gratifying  in  relieving  suffering,  deformity  and  disability. 

Materials  required:  Several  long  probes  provided  with  an  eye  at  one  end; 
a  supply  of  No.  12  tubular  woven  silk. 

The  Operation. — Step  i. — Make  a  one-inch  incision  through  the  skin  in  the 
midline  of  the  front  of  the  forearm  immediately  above  the  wrist.     (Fig.  839,  a.) 

Step  2. — Introduce  a  probe  under  the  skin  through  incision  a.  Pass  the 
probe  upwards  and  outwards  to  the  point  b  near  the  elbow.  At  this  point 
incise  the  skin  and  push  the  point  of  the  probe  out  through  the  incision. 


Fig.  839. 


Fig.  840. 


Step  3. — Take  a  double  line  of  silk  more  than  twice  as  long  as  the  arm  and 
catch  its  mid-point  with  a  haemostat.  Protect  one  half  of  the  silk  by  wrapping 
it  in  a  towel  and  thread  the  other  half  through  the  eye  of  the  probe.  Pull  the 
probe  and  with  it  the  silk  out  through  incision  b.  The  haemostat  attached  to 
the  silk  prevents  too  much  being  pulled  out.  A  double  line  of  silk  now  lies 
in  the  subcutaneous  tunnel  a-b  made  by  the  probe. 

Step  4. — Reintroduce  the  probe  through  the  incision  b  and  bring  it  and  the 
silk  out  through  incision  c  made  near  the  insertion  of  the  deltoid. 

Step  5. — Pass  a  second  probe  through  incision  a,  upwards  and  inwards  and 
make  it  emerge  through  incision  d.  The  half  of  the  silk  line  which  was  wrapped 
in  a  towel  is  now  unwrapped  and  threaded  through  the  eye  of  the  probe.  Pull 
the  probe  and  with  it  the  silk  out  through  incision  d.     Remove  the  haemostat 


752  OPERATIONS    ON   VEINS. 

from  the  middle  of  the  silk  so  that  the  loop  of  silk  becomes  buried  mider  the 
skin  at  a. 

Step  6. — In  the  same  fashion  pass  the  silk  under  the  skin  from  d  to  c. 

Step  7. — Reintroduce  both  probes  through  incision  c  and  pass  them  under 
the  skin  round  the  shoulder  to  emerge  through  incision  /  made  at  the  posterior 
border  of  the  deltoid  (Fig.  840). 

Step  8. — In  the  same  manner  bury  a  double  line  of  silk  under  the  skin  of  the 
back  of  the  arm  along  the  lines  g  h  f  and  g  k  f.  There  are  now  eight  threads 
emerging  through  incision  /. 

Step  9. — Take  a  long  probe,  cut  off  the  ends  of  two  of  the  emerging  threads 
so  that  they  are  four  inches  shorter  than  the  probe  and  thread  them  into  the 
eye.  Thrust  the  probe,  eye  first,  through  incision/ and  make  it  penetrate  under 
the  skin  of  the  back.  The  probe  being  longer  than  the  silk,  unthreads  itself. 
Withdraw  the  probe  carefully  leaving  the  two  silk  threads  to  occupy  its  track. 

Repeat  this  manoeuvre  until  all  the  threads  which  emerged  at  /  have  been 
tucked  in  various  directions  into  subcutaneous  tissues  of  the  back. 

Step  10. — Close  all  the  incisions  with  sutures. 

Handley  writes  ("Brit.  Med.  Journ.,"  April  9,  1910). 

The  choice  of  cases  for  lymphangioplasty. 

"The  analysis  of  my  cases  shows  that  lymphangioplasty  is  contraindicated 
in  cases  where  a  general  anaesthetic  cannot  be  borne,  and  in  cases  where  silk 
threads  would  have  to  pass  through  cancerous  tissue.  It  is  also  inadvisable  to 
operate  where  there  is  growth  present  about  the  shoulder,  if  the  pain  is  mainly 
an  axillary  one,  or  is  a  lancinating  pain  shooting  down  the. arm.  In  the  presence 
of  pleural  effusion  or  secondary  growths  the  benefits  of  the  operation  are 
transient,  but  the  shortest  period  of  relief  may,  under  the  circumstances,  be 
considered  by  the  patient  as  worth  having. 

"  Minor  degrees  of  obstruction  to  the  return  of  lymph  from  the  arm  are  not 
infrequently  met  with  in  breast  cancer.  The  operation  of  lymphangioplasty 
should  not  be  applied  indiscriminately,  but  should  be  reserved  for  the  severer 
degrees  of  lymph-stasis  in  which  other  modes  of  treatment  are  powerless. 

"The  axillary  scarring  which  necessarily  follows  removal  of  glands  may 
sometimes  lead  to  persistent  oedema  of  the  arm,  usually  slight  in  amount. 
In  such  cases  the  application  of  a  bandage  and  the  elevation  of  the  arm  on  an 
inclined  plane  for  one  or  two  hours  a  day  will  usually  suffice.  In  other  cases, 
which  ultimately  develop  into  the  true  brawny  arm,  the  lymph  obstruction  is 
partial  only.  In  such  cases,  although  the  arm  may  attain  a  very  considerable 
size,  the  oedema  is  soft  and  pits  freely  on  pressure.  Postural  treatment  by 
elevation  will  sometimes  in  this  stage  reduce  the  size  of  the  arm  considerably, 
and  will,  to  some  extent,  relieve  the  pain.  The  necessity  of  operation  is  thus 
for  a  time  deferred,  but  the  relief  obtained  is  not  to  be  compared  with  that 
resulting  from  lymphangioplasty.  It  appears,  moreover,  to  be  very  transient, 
and  in  many  cases  even  before  the  oedema  has  become  solid,  postural  treat- 
ment is  intolerable  because  it  severely  aggravates  the  pain.     This  fact  is  easily 


LYMPIL\NGIOPLASTY. 


753 


explicable,  since  the  lymph  from  the  forearm,  flowing  easily  upwards  into  the 
arm  and  meeting  obstruction  there,  distends  the  tissues  of  the  upper  arm  to  an 
unbearable  extent." 

Elephantiasis. — Handley  has  applied  lymphangioplasty  to  the  treatment 
of  various  cedemas  of  the  lower  extremity — elephantiasis,  Milroy's  disease 
(congenital  oedema),  etc. — but  finds  that  while  temporary  benefit  was  obtained 
the  condition  always  promptly  recurred. 

W.  Clarke  ("  St.  Bartholomew's  Hosp.  Reports,"  xlv,  1909,  Zent.,  1910,  No. 
18)  reports  a  case  of  oedema  of  the  leg  of  uncertain  origin  but  of  nine  years' 
duration.  Implantation  of  a  thread  on  the  inner  side  from  the  dorsum  of  the 
foot  to  above  the  knee  gave  distinct  improvement. 

A.  B.  Mitchell  ("B.  M.  J.,"  Nov.  20,  1909)  reports  a  case  of  solid  oedema  of 
the  eyelids  on  both  sides  which  followed  a  severe  attack  of  erysipelas  and  re- 
sisted all  ordinary  treatment.  Handley's  operation  was 
performed  as  follows: 

1.  Make  the  very  small  curved  incision  a  (Fig.  841) 
on  the  upper  eyelid.  Through  incision  a  pass  a  probe 
under  the  skin  to  the  point  h  at  the  outer  margin  of  the 
orbit;  expose  the  point  of  the  probe  by  incising  the  skin 
at  b.  Thread  a  strand  of  coarse  silk  on  to  the  eye  of  the 
probe  and  pull  it  through  the  subcutaneous  tunnel  made 
by  the  probe  between  a  and  b. 

2.  Similarly  incise  the  lower  lid  at  c  and  pass  a  strand 
of  silk  under  the  skin  to  emerge  at  incision  h. 

3.  Pass  a  probe  through  incision  b  and  push  it  down- 
wards under  the  skin  to  the  point  d  where  a  small  incision 
permits  the  probe  to  emerge.  Thread  the  two  strands  of 
silk  emerging  at  b  through  the  eye  of  the  probe  and  pull 
them  through  the  subcutaneous  tunnel  b  d. 

4.  With  a  probe  or  director  introduced  through  in- 
cision d  made  a  small  pouch  under  the  skin  below  d  and 
into  this  tuck  the  ends  of  the  threads. 

5.  Close  all  skin  wounds. 

In  Mitchell's  case  one  of  the  threads  caused  irritation  and  had  to  be  re- 
moved; the  other  remained  in  situ;  the  result  was  good. 

In  the  case  of  a  young  soldier  who  suffered  from  solid  oedema  of  the  left 
side  of  the  face  and  lips  due  to  erysipelas  following  excision  of  enlarged  cervical 
glands  Mitchell  implanted  two  silk  threads  the  upper  ends  of  which  were 
fastened  to  the  fascia  covering  the  masseter,  the  lower  ends  being  tucked  into 
the  loose  tissue  behind  the  clavicle. 

"The  result  was  entirely  satisfactory;  the  threads  never  gave  the  slightest 
trouble;  the  face  resumed  the  natural  contour." 


Fig.  841. 


CHAPTER  LXVI. 

OPERATIVE   TREATMENT   OF   SIMPLE   FRACTURES,   EXCLUSIVE 

OF   THOSE    INVOLVING   ARTICULATIONS   AND    OF    SOME 

SPECIAL  FRACTURES. 

Until  recently  all  closed  (simple)  fractures  were  treated  without  operation; 
to-day  most  of  them  are  and  ought  to  be  exempt  from  operation.  All  open 
(compound)  fractures  demand  operation. 

When  it  is  evident  that  the  fractured  bones  cannot  be  reduced  by  manipulation 
and  traction  or  when,  after  being  reduced,  they  cannot  be  held  in  position  by 
suitable  splints  or  appliances,  then  operation  is  demanded.  The  operation, 
though  demanded  is  almost  never  urgent,  hence  there  is  always  plenty  of  time 
in  which  to  arrange  for  proper  surroundings  and  assistance  which  is  fortunate 
as  perfect  asepsis  is  an  absolute  necessity.  There  are  three  periods  at  which 
operation  may  be  undertaken. 

(A)  Immediate  Operation. — Immediately  after  receipt  of  injury  the  tissues 
are  freshly  lacerated;  there  is  no  effusion  from  irritation;  the  lymphatics  are  not 
clogged  with  dead  material  being  removed.  Unfortunately,  from  the  trauma, 
much  tissue  is  so  injured  that  its  resisting  power  is  lowered  and  hence  an 
amount  of  accidental  infection,  which  would  be  harmless  in  a  wound  made 
during  an  ordinary  operation,  might  lead  to  serious  consequences.  Immediately 
after  injury  the  conditions  are  therefore  partly  favorable  and  partly  unfavorable 
for  operation.     Arbuthnot  Lane  favors  early  operation. 

(B)  Delayed  Operation. — Within  a  few  hours  of  the  receipt  of  injury  the 
extravasated  blood  clots  in  the  tissues;  coagulable  lymph  is  effused  throughout 
the  injured  area;  the  normal  lymphatic  drains  of  the  part  are  either  overworked 
or  clogged;  the  bruised  but  still  living  tissues  have  not  recovered  tone;  the 
whole  injured  area  is  in  the  least  favorable  condition  to  withstand  any  accidental 
infection.     This  unfavorable  condition  persists  for  about  seven  days. 

(C)  Late  Operation. — During  the  second  week  after  injury  the  injured 
tissues  have  recovered  tone;  much  of  the  extravasated  blood,  etc.,  has  been 
absorbed;  the  lymphatic  drainage  system  is  in  good  working  order;  the  ends 
of  the  broken  bones  have  gone  through  the  process  preparatory  to  repair.  All 
conditions  are  favorable  for  operation.  During  the  period  of  delay  the  usual 
means  of  reducing  and  treating  the  fracture  have  been  faithfully  tried  and  their 
failure  demonstrates  the  necessity  of  operation.  Some  time  during  the  second 
week  is  the  period  of  choice  for  operation — at  a  later  date,  nature's  efforts  at 
repair  and  the  occurrence  of  contractures,  etc.,  would  seriously  interfere  with 
operative  reduction. 

754 


FRACTURES. 

PRINCIPLES  OF  OPERATION. 


755 


I.  Preparation  of  Patient. — If  necessary  expend  several  days  in  cleaning 
the  skin  of  the  part.  Scrub  repeatedly  with  soft  soap  and  hot  water,  using 
the  nail-brush  or,  better,  some  form  of  scrub-cloth.  In  the  interval  keep  the 
parts  covered  with  moist  dressings  or  soap  poultice.  On  the  evening  preceding 
operation,    after   thorough  scrubbing,  apply  an  antiseptic  poultice.     On  the 


operating-table  repeat  the  scrubbing  and  sterilize  the  skin  by  rubbing  into  it 
Harrington's  solution  or  some  other  reliable  antiseptic. 

II.  Make  an  appropriate  incision  where  it  will  do  least  harm  and  give  the 
most  free  possible  access.  Make  the  incision  too  long  rather  than  too  short. 
As  soon  as  the  skin  is  completely  divided  exclude  it  from  the  rest  of  the  wound 
by  sterile  cloths  held  in  place  by  a  few  stitches  or  by  volsella  forceps.  Complete 
the  exposure  of  the  fracture  by  blunt  and  sharp  dissection. 


Fig.  843. 

Never  tauch  the  wound  with  the  bare  hand;  make  all  necessary  manipulations 
with  instruments  (Konig's  rule)  or  wear  rubber  gloves.  Do  not  let  such  parts 
of  instruments  as  have  touched  the  skin  of  the  patient  or  the  bare  hand  of  the 
surgeon  enter  the  wound  (Lane). 

III.  Having  thoroughly  exposed  the  ends  of  the  bone,  remove  all  blood- 
clot  and  material  intervening  between  them.  Fritz  Konig  advises  against 
a  too  thorough  removal  of  all  material  between  the  fractured  sur- 
faces, as  nature  will  attend  to  this  and  much  of  the  material  here 
present  is  of  value  in  the  formation  of  callus;  it  is  only  necessary  to 
remove  such  structures  as  will  probably  interfere  with  union. 
Konig  writes  ("Archiv.  fiir  klin.  Chir.,"  Ixxvi,  725),  "except  in 
resections  (when  union  has  been  despaired  of)  or  when  there  is 
abnormal  effusion  into  involved  joints,  we  do  not  concern  ourselves  int.  splint. 
much  with  blood-clots." 

Lane,  however,  thinks  that  bones  ought  to  unite  with  practically  no  callus. 

Now  attend  to  hemostasis  and  bring  the  fragments  into  apposition  by  means 
of  traction  combined  with  the  leverage  action  of  powerful  long-handled  forceps. 
Lane's  forceps  are  shown  in  Fig.  842.     They  are  so  constructed  as  to  grasp  the 


756 


OPERATIVE    TREATMENT    OF    SIMPLE    FRACTURES. 


I'^IG.   845. —  iLaiie. 


I-ic.  846. — (Lane.) 


Fig.  847.— (I,(j«p.) 


P^IG.   848. — {Lane.) 


FR.'VCTURES. 


757 


Fig.  849. — -(Lane.) 


758 


OPERATIVE    TREATMENT    OF    SIMPLE    FR.\CTURES. 


Fig.  S50. — iJLane.) 


FRACTURES. 


759 


Fig.  851  .\.~{Lane.) 


760 


OPERATIVE    TREATMENT    OF    SIMPLE    FRACTURES. 


Fig.  851  B.—-{Lane.) 


FRACTURES. 


761 


bones  firmly  and  yet  not  exert  injurious  pressure.  Different  sizes  of  forceps 
are  required  for  large  bones,  as  the  femur,  and  small  bones,  like  the  ulna. 
The  forceps  hold  the  fragments  in  place  admirably  while  screw  nails,  staples, 
or  metal  splints  are  being  applied.  If  the  fragments  tend  to  remain  in  ap- 
position, close  the  wound  with  or  without  drainage  and  treat  as  a  simple  fracture. 
If  there  is  any  doubt  as  to  the  maintenance  of  apposition  it  is  necessary  to  in- 
sure it  by  means  of  sutures  (wire  or  chromic  gut),  pegs,  screw  nails  (Lane), 


Fig.  852. — [Lane.) 


intramedullary  bone  plates  or  tubes,*  staples  (Jacoel)  (Fig.  843),  buried  metal 
splints  (Fig.  844),  Freeman's  apparatus,  etc.,  etc.  (see  p.  772). 

IV.  Close  the  wound  with  or  preferably  without  drainage.  Dress.  Im- 
mobilize. 

Figures  845,  846,  847,  848,  849,  850,  851,  852,  853,  854,  kindly  put  at 
the  author's  disposal  by  Mr.  Lane,  explain  better  than  words  the  uses  of 
buried  metal  splints. 

*  Carleton  Flint  used  pegs  made  from  fresh  ox  bone.  These  pegs,  at  first  square  in  sec- 
tion, are  roughly  rounded  with  a  file  and  sterilized  by  boiling. 


762 


OPERATIVE    TREATMENT    OF    SIMPLE    FRACTURES. 


Fig.  853. — {Lane.) 


Fig.  854. — {Lane.) 


CHAPTER  LXVII. 
COMPOUND  OR  OPEN  FRACTURES. 

Practically  every  fracture  communicating  with  the  open  air  through  a  wound, 
no  matter  how  trivial  the  wound  may  appear,  ought  to  be  subjected  to  opera- 
tion. The  object  of  the  operation  is  the  treatment  of  the  deep  wound;  treat- 
ment of  the  fracture  is  a  secondary  consideration  and  may  be  carried  out  either 
at  this  time  or  later,  as  may  seem  best.  The  method  of  treatment  varies  accord- 
ing to  the  severity  of  the  injury,  the  amount  of  dirt  ingrained  into  the  wound, 
and  the  conditions  surrounding  the  patient.  An  elaborate  method  of  operating 
with  fixation  of  the  fractured  bones  is  very  proper  when  a  good  operating-room 
and  good  assistance  are  available  and  yet  may  be  quite  improper  under  less 
favorable  circumstances. 

Example. — Compound  fracture  middle  of  humerus;  small  wound  through 
skin;  much  laceration  muscles.  Unfavorable  surroundings.  Treatment 
adopted:  Free  enlargement  skin  wound;  loose  packing  with  gauze;  immobiliza- 
tion in  comfortable  position,  but  no  attempt  at  exact  reposition  of  bones.  Re- 
moval of  pack  in  about  48  hours.  Application  of  dressings  and  immobilization 
as  before.  Reduction  of  fracture  on  eight  day.  Careful  immobilization.  If 
it  had  been  easy  to  reduce  the  fracture  and  keep  it  reduced  during  the  days 
when  the  woimd  required  attention,  immediate  reduction  would  have  been 
effected,  but  as  it  was  the  patient  was  comfortable,  the  wound  healed  well, 
and  no  time  was  lost. 

W'lien  it  is  evident  that  injury  to  the  vessels,  etc.,  of  the  part  has  destroyed 
all  hope  of  maintaining  the  nutrition  of  the  parts  distal  to  the  fracture,  ampu- 
tation must  be  done;  under  other  circumstances  conservative  operation  is 
imperative. 

An  operation  for  open  fracture  of  the  tibia  may  be  taken  as  typical. 

OPERATION  FOR  OPEN  FRACTURE  OF  THE  TIBIA. 

Step  I. — Anaesthetize.  Scrub  the  whole  leg  with  soap  and  hot  water,  using 
a  wash  cloth.  Shave  the  leg.  Scrub  the  whole  leg  with  turpentme,  gasoline, 
or  ether  to  remove  grease.  Scrub  once  more  with  soap  and  water.  Scrub  with 
alcohol.  Scrub  with  some  reliable  antiseptic  solution,  preferably  Harrington's 
solution  (commercial  alcohol  (94  per  cent.),  640  c.c;  hydrochloric  acid,  60  c.c; 
water,  300  c.c;  corrosive  sublimate,  o.  8  gram).  Instead  of  the  above  elaborate 
classical  preparation  one  may  use  Grossich's  plan,  viz.,  avoid  the  use  of  water, 
shave  off  the  hair  (dry),  paint  with  tincture  of  iodine.  Apply  an  elastic  con- 
strictor. 

763 


764 


COMPOUND    OR    OPEN    FRACTURES. 


Step  2. — Enlarge  the  skin  wound  freely  so  that  every  nook  and  cranny  of 
the  deep  wound  becomes  accessible.  With  gauze  sponges,  gloved  finger,  and 
instruments  remove  all  foreign  material,  blood-clots,  etc.  Dissect  away  the 
ragged  skin  around  the  wound  also  all  portions  of  tissue  so  injured  that  they 
cannot  live.  Remove  completely  all  detached  fragments  of  bone.  These 
fragments  Macewen  scrubs  thoroughly,  lays  aside  in  a  warm  aseptic  solution 
and  reimplants  with  good  effect,  when  necessary.  Few  surgeons  follow  Mace- 
wen's  lead  in  this. 

Fragments  of  bone  still  attached  to  the  shaft  by  periosteum  may  be  cleansed 
and  retained.  Remove  all  tissues  which  will  interfere  with  union  by  becoming 
interposed  between  the  fractured  surfaces.  With  retractors  open  all  torn 
tissue  planes  and  spaces;  clean  such  thoroughly  with  douche  and  mop.     If 

much  dirt  has  gained  access,  mop  out  the 
whole  wound  vnth  pure  liquid  carbolic  acid 
and  immediately  follow  this  by  mopping 
with  alcohol  to  dilute  and  remove  the  acid. 
Instead  of  carbolic  acid  and  alcohol,  Har- 
rington's solution  may  be  used.  Provide 
free  drainage  for  every  part  of  the  wound 
through  counter-pimctures  when  necessary. 
Reduce  the  fracture.  If  necessary  for 
fixation,  unite  the  fractured  surfaces  by 
sutures  of  wire  or  catgut  or  by  means  of 
the  pegs,  etc.,  described  elsewhere.  The 
objection  to  the  use  of  wire,  pegs,  nails, 
etc.,  is  the  irritation  which  they  are  likely 
to  keep  up  if  the  wound  is  or  becomes 
infected.  In  an  open  fracture  of  the  femur,  where  asepsis  was  evidently  un- 
attainable, C.  H.  Mayo  mortised  the  bones  together  (Fig.  855)  so  that  fixation 
was  obtained  without  employing  any  foreign  body.  Remove  the  elastic  con- 
strictor. Attend  to  hemostasis  by  means  of  forceps,  ligatures,  and  hot  water. 
See  that  the  drainage-tubes  are  in  place  and  not  clogged. 

Step  3. — Partially  close  the  external  wound.  Dress.  Immobilize.  (Hod- 
gen's  splint  is  excellent.) 

In  very  complicated  cases  the  author  has  often  left  the  wound  wide  open, 
filling  it  loosely  with  gauze;  if  after  a  few  days  it  is  evident  that  asepsis  has 
been  attained  the  wound  may  be  closed  in  whole  or  in  part;  if  asepsis  has  not 
been  attained  the  openness  of  the  wound  is  a  great  element  of  safety.  Always 
remember  that  treatment  of  the  wound  is  of  incomparably  greater  importance 
than  reduction  of  the  fracture.  If  reduction  of  the  fracture  does  not  interfere 
with  drainage  and  woimd  treatment,  then  immediate  reduction  is  indicated; 
if  reduction  interferes  in  any  way  with  efficient  drainage  then  partial  reduction 
plus  as  thorough  as  possible  immobilization  is  the  treatment  of  choice  until 
the  drains  are  removed  when  reduction  should  be  carried  out.     During  the 


Fig.  855. 


FRACTURES.  765 

after-treatment  some  form  of  interrupted  splint  is  a  great  boon,  as  it  permits 
the  dressings  to  be  changed  with  the  least  possible  disturbance  of  the  parts. 

An  open  fracture  at  the  articular  end  of  a  bone  may  involve  the  joint  in 
one  or  two  ways:  (a)  A  split  or  fissure  may  extend  from  the  main  site  of  fracture 
and  the  external  wound  into  the  joint.  If  such  a  fracture  is  seen  early  it  is 
very  improbable  that  infection  will  have  reached  the  joint  unless  the  fissure  or 
split  is  short,  i.  e.,  unless  the  distance  from  the  point  of  articular  involvement  to 
the  external  wound  is  short.  Under  the  above  favorable  conditions,  treat 
the  case  a.s  a  compound  fracture  without  articular  involvement. 

(b)  There  is  free  communication  between  the  external  wound  and  the  joint. 
Treat  the  fracture  secundem  ariem;  treat  the  joint  by  arthrotomy,  i.e.,  provide 
free  drainage  as  if  arthritis  had  already  developed.  The  treatment  of  the  con- 
sequences of  articular  infection  will  he  considered  elsewhere. 


CHAPTER  LXVIII. 
UNUNITED  FRACTURE.     PSEUDARTHROSIS. 

The  local  causes  of  non-union  of  fractures  are  usually  (a)  separation  of  the 
fragments,  (b)  insufficient  or  improper  immobilization,  and  (c)  most  important 
of  all,  interposition  of  muscle,  fascia,  or  fat  between  the  fragments.  The 
principles  of  operative  treatment  consist  in  (a)  removal  of  interposed  tissue; 
(b)  freshening  of  the  ends  of  the  bones;  (c)  obtaining  and  maintaining  apposition 
of  the  fragments.  If  these  principles  are  carried  out  with  cleanliness,  union 
is  sure,  provided  that  the  local  and  general  vitality,  /'.  e.,  the  recuperative  power, 
is  sufficient. 

Often  long-continued  non-union  results  in  contracture  or  shortening  of  the 
soft  parts  and  this,  unless  corrected,  may  prevent  either  the  obtaining  or  main- 
taining of  apposition  of  the  fragments.  Where  moderate  contracture  is  present 
Treves  very  wisely  recommends  that  extension  be  applied  to  the  limb  for  a 
week  or  more  prior  to  operation.  Edward  Martin,  in  the  case  of  an  ununited 
fracture  of  the  femur  with  2  1I2  inches  of  shortening,  having  failed  to 
attain  results  by  the  usual  means  of  traction,  devised  the  following  method: 
"It  consists  in  a  long,  strong  canvas  strip  pocketed  in  the  middle  and  looped 
at  the  ends.  The  bones  at  the  seat  of  fracture  are  freed,  the  pocket  is  slipped 
over  the  proxinal  end  of  the  distal  fragment,  the  ends  of  the  canvas  strip  are 
carried  in  the  long  axis  of  the  limb  and  in  the  loops  is  fixed  a  cord  to  which  are 
attached  the  weights.  By  thumb  pressure  the  bone  is  kept  from  angling  out 
of  the  wound,  and  weights  up  to  100  pounds,  or  more,  are  attached  to  the  rope. 
In  from  three  to  five  minutes  the  shortening  is  overcome.  Only  those  structures 
which  interfere  with  proper  placement  are  stretched,  and  this  is  done  so 
thoroughly  that  there  is  but  slight  tendency  to  the  reproduction  of  deformity" 
("Surg.,  Gyn.,  Obst.,"  Jan.,  1910). 

Ochsner  prefers  gradual  extension;  he  says  "the  only  thing  that  is  peculiar 
about  the  method  is  the  application  of  rubber  adhesive  strips  to  as  high  a  point 
above  the  seat  of  fracture  as  is  possible. 

For  instance,  instead  of  applying  the  rubber  adhesive  up  to  the  fracture,  it 
should  be  applied  over  the  entire  length  of  the  thigh,  then,  with  no  more  than 
24  pounds  of  weight,  we  have,  in  every  fracture  where  there  has  not  been  a 
union,  been  able  to  stretch  the  muscles  sufficiently  to  replace  the  fractures  without 
making  a  resection  of  the  ends.  In  cases  where  there  is  a  union  in  malposi- 
tion, the  muscles  will  stretch  to  a  marked  extent.  Extension  may  be  supple- 
mented in  some  cases,  by  preliminary  division  of  the  contracted  tissues,  al- 
though such  division  is  more  commonly  done  at  the  time  of  the  major  operation. 

766 


NON-UNION. 


767 


The  aim  of  the  surgeon  must  be  to  so  operate  that  whatever  means  of  fixation 
and  immobiHzation  (pegs,  wire,  splints,  etc.)  is  used,  its  function  may  be  as 
nearly  as  possible  prophylactic,  i.  e.,  the  fragments  of  bone  ought  to  be  so  pre- 
pared that  they  tend  to  remain  in  apposition. 

METHODS  OF  OPERATING. 

Step  I. — Exposure  of  the  Bone. — Select  that  route  to  the  site  of  fracture 
which  is  shortest  and  which  will  necessitate  least  damage  to  the  tissues.  Re- 
member the  situation  of  important  structures  (e.  g.,  the  musculo-spiral  nerve  in 
the  arm)  so  as  to  avoid  injuring  them.  If  possible  penetrate  to  the  bone  be- 
tween muscles  rather  than  through  a  muscle.  Usually  a  longitudinal  incision 
is  best. 

The  use  of  an  elastic  constrictor  is  optional,  though  it  is  preferable  to  avoid 
its  use  whenever  possible.  At  the  point  selected  make  a  vertical  cut  through 
the  skin  down  to  but  not  through  the  deep  fascia.  To  find  an  intermuscular 
septum  it  may  be  necessary  to  reflect  the  skin  from  the  fascia  for  a  short  distance 


Fig.  856. 


Fig.  857. 


on  one  or  both  sides  of  the  incision.  Divide  the  fascia  over  an  intermuscular 
septum  and  by  combined  sharp  and  blunt  dissection  penetrate  the  septum  to 
the  bone.  With  retractors  expose  the  bone.  The  length  of  the  wound  must  be 
sufficient  to  give  free  access  to  the  site  of  fracture.  A  small  incision  inevitably 
leads  to  much  bruising  and  damage  to  the  tissues  during  the  rest  of  the  operation. 
With  a  periosteal  elevator  or  rugine  separate  enough  of  the  periosteum  (if 
possible  en  masse  with  the  attached  muscles)  to  permit  of  a  thorough  appre- 
ciation of  the  conditions  to  be  dealt  with.  [Amount  of  fibrous  tissue  between 
the  fragments;  extent  of  separation;  amount  of  bone  atrophy;  obliquity  of  the 
ends  of  the  bone,  etc.,  etc.] 

Instead  of  exposing  the  fascia  by  a  vertical  incision  one  may  reflect  the  skin 
as  a  flap  by  means  of  I-^  U-,  or  n-shaped  incision.  After  the  fascia  is  exposed 
the  rest  of  the  operation  is  as  described  above. 


768 


UNUNITED    FRACTURE.       PSEUDARTHROSIS. 


Step  2. — Preparation  of  the  Ends  of  the  Bone  for  Their  Union. — The 
preparation  of  the  ends  of  the  bone  depends  on  the  conditions  found  at  the 
site  of  fracture.  The  bones  may  be  united  by  fibrous  tissue,  their  ends  may  be 
conical  from  atrophy,  there  may  be  a  wide  separation  between  them  or  one 
fragment  may  have  overridden  the  other,  causing  much  shortening.  The 
line    of    fracture    may  be  transverse,   oblique,  or  irregular,     (a)   Dissect  all 


Fig.  SsH. 


Fig.  859. 


foreign  material  (fibrous  tissue,  muscle,  etc.)  from  between  the  bones,  (b) 
If  possible,  make  each  fragment  of  bone  in  turn  protrude  from  the  wound  and 
vivify  it  by  sawing  off  thin  slices  of  the  bone  until  a  healthy  bleeding  surface  is 
obtained,  (c)  If  it  is  impossible  to  make  the  ends  of  the  bone  protrude,  vivify 
them  in  situ  by  means  of  a  finger  or  a  Gigli  wire  saw  or  a  chisel. 

As  a  rule,  an  oblique  fracture  can  be  best  vivified  with  a  chisel,  a  transverse 


Fig.  860. 


Fig.  861. 


fracture  or  one  where  the  ends  have  become  conical,  with  a  saw.  (d)  When 
vivifying  the  ends  of  the  bone  it  is  often  possible  to  so  shape  them  that  the  one 
fragment  will  mortise  into  the  other  and  thus  tend  to  remain  in  position.  A 
chisel  or  gauge  is  the  best  instrument  with  which  to  shape  the  ends  of  the  bone. 
Figures  856,  857,  858,  859,  860,  861  show  various  methods  of  vivifying  and 
modeling  the  ends  of  the  bones. 


NON-UNION. 


769 


Fig.  862.  Fig.  863. 

Fig.  862. — Improper  application  of  wire. 

Fig.  863. — Proper  application  of  wire.     Note  the  wire  is  at  right  angles  to  the  Hne  of 
fracture. 


Fig.  864. 


Fig.  866. 


Fig.  867. 


Fig.  868.  Fig.  869.  Fig.  870. 

Figs.  868,  869,  and  870. — {Monod  and  Vanvert.) 


49 


770 


UNUNITED    FRACTURE.       PSEUDARTHROSIS. 


Step  3. — Union  of  the  Bones. — If  the  fragments  show  a  marked  tendency  to 
remain  in  apposition,  the  wound  may  be  closed  and  the  case  treated  by  sphnts, 
etc.,  Hke  any  ordinary  fracture.  Unfortunately,  the  above  is  not  commonly 
sufficient  and  it  becomes  necessary  to  hold  the  bones  together  by  some  means 
applied  directly  to  them.  The  methods  devised  for  attaining  direct  union  of 
the  fragments  are  legion — a  few  of  the  principal  ones  will  be  given  here 

Method  A. — Suture  of  Wire  or  Catgut. — Figures  862,  863,  864,  865,  866, 
867,  868,  869,  870,  871,  872  show  how  transverse  or  oblique  fractures  may  be 


Fig.  871. — {Lejars.) 


fastened  together  with  stout  wire  or  stout  chromicized  catgut.  If  wire  is  used, 
the  ends,  after  twisting,  must  be  cut  off  short  and  any  sharp  protruding  ends 
must  be  hammered  flat  or  directed  into  the  bone  so  as  not  to  lacerate  the 
soft  parts.     Most  surgeons  use  silver  or  aluminum-bronze  wire. 

Method  B.— Fixation  by  Nails  or  Bone  Pegs. — Where  the  fractured 
surfaces  are  oblique,  bore  a  hole  transversely  through  both  fragments — tem- 
porarily leave  the  drill  in  siki.  With  a  second  drill  bore  another  hole  through  both 
fragments;  remove  this  drill  and  replace  it  by  a  bone  peg.  Remove  the  drill 
first  introduced  and  replace  it  also  by  a  bone  peg.  The  drill  left  in  situ  keeps 
the  fragments  in  good  position  while  the  first  peg  is  being  introduced.     Bone 


BONE    FIXATION. 


771 


pegs  are  easily  made  from  a  bone  knitting  needle  of  convenient  thickness  and 
are  sterilized  by  being  boiled.  When  the  pegs  have  been  driven  into  position, 
any  part  which  may  protrude  must  be  cut  off  flush  with  the  bone.  Instead  of 
bone  pegs  metal  nails  or  screws  may  be  used  in  the  same  way. 

Figures  873  and  874  show  the  application  of  pegs.  Jacoel  and  Dujarier 
have  devised  useful  metal  staples  to  take  the  place  of  nails  or  screws  (Fig.  875). 

Method  C. — Fixation  by  Drills  or  Long  Metal  Nails. — This  method  is  the 
same  as  B,  except  that  the  drills  used  to  perforate  the  bone  are  left  in  situ  with 


Fig.  87 2.--  L.jars.) 

their  proximal  ends  protruding  through  the  wound  in  the  soft  parts.  After 
two  or  three  weeks  the  drills  become  loose  and  are  easily  removed.  Both 
methods  B  and  C  have  given  the  author  much  satisfaction. 

Method  D. — Fixation  by  Intra-meduUary  Pegs. — Prepare  beforehand 
several  bone  or  ivory  pegs  of  different  sizes  so  as  to  be  sure  to  have  one  about 
the  caliber  of  the  central  cavity  of  the  bone.  Bend  the  limb  so  that  the  end  of 
the  lower  fragment  of  bone  is  easily  accessible — lightly  drive  a  prepared  peg 
into  the  medullary  cavity  for  a  distance  of  i  to  i  1/2  inches.  Manipulate  the 
Hmb  so  that  the  end  of  the  peg  protruding  from  the  lower  fragment  enters  the 
medullary  canal  of  the  upper  fragment  (Fig.  876). 


772 


UNUNITED    FRACTURE.       PSEUDARTHROSIS. 


Method  E. — Fixation  by  Means  of  "Fish  Plates."     Internal  Splinting. 

— The  best  plates  are  those  of  Arbuthnot  Lane  made  of  stout  steel.  Such  may 
be  obtained  in  various  sizes.  The  thin  silver  plates  commonnly  used  are  so 
delicate  that  they  may  break  in  situ  and  cause  trouble.  This  accident  has 
occurred  to  the  author.  The  screws  are  of  metal  and  should  be  a  trifle  over 
1/2  inch  in  length.  Figures  848  and  850  show  clearly  the  application  of  "fish 
plates"  to  a  bone. 


Fig.  873. 


Fig.  874. 


Method  F. — Fixation  by  Means  of  Long  Screws  and  External  Clamps. — 

This  method  has  been  recommended  by  Keetley,  Parkhill,  and  Freeman. 
The  application  of  Parkhill's  most  ingenious  apparatus  is  difficult  because  of 
its  complexity. 

Freeman,  by  using  strips  of  hard  wood  backed  by  steel  plates  (Fig.  877) 
has  rendered  the  method  exceedingly  simple.  The  attached  figures  sufficintly 
describe  the  procedure.     Figures  878  and  879  show  an  exceedingly  compli- 


FiG.  875. 

cated  apparatus  on  the  same  principles  which  has  given  Lambotte  excellent 
results. 

Method  G. — Fixation  by  Ferrules  of  Decalcified  Bone.  (Senn). — 
Figure  880  sufiiciently  shows  this  method. 

Step  4. — Closure  of  the  Wound. — Have  an  assistant  hold  the  limb  steady 
in  good  position.  Close  the  periosteal  wound  with  fine  catgut  sutures.  Close  the 
rest  of  the  wound  secundem  arlem,  with  or  without  drainage.  Apply  dressings. 
Immobilize  by  plaster  of  Paris  or  splints.     Treat  as  an  ordmary  fracture. 


NON-UNION. 


773 


Early  in  this  chapter  it  was  stated  that  if 
the  principles  of  treatment  here  outlined  are 
carried  out  with  cleanliness  union  is  sure, 
provided  that  the  local  and  general  vitality,  i.e., 
the  recuperative  power,  is  stifficient.  Where  the 
general  vitality  is  low  it  must  be  stimulated  by 
proper  diet,  tonics,  and  especially  by  the  open 
air.  Where  the  local  vitality  is  low,  although 
the  wound  may  heal  by  primary'  union,  yet  the 
fracture  may  not  consolidate,  the  bone-forming 
cells  have  not  done  their  work.  To  stimulate 
repair,  massage  is  of  value  and  the  use  of  ap- 
paratus which  permits  of  ambulatory  treatment 
may  also  aid. 

V.  Biingner  ("Archiv.  fur  klin.  Chir.,"  xli, 
185)  recommends  that  primary  union  be  not 
sought  in  cases  where  atrophy  of  the  fractured 
ends  of  the  bone  is  present,  but  that  after  these 
structures  are  fixed  together  by  any  of  the 
methods  described,  the  wound  be  packed  with 
gauze  and  allow  to  heal  by  granulation. 
There  is  much  to  be  said  in  favor  of  this  suggestion. 


Fig.  876. — {Lejars.) 
P,  Upper  fragment;   P',   Lower 
fragment;  F,  Peg;  JSI,  Muscle;  G, 
Fat. 


Fig.  877. — \Freeman.) 


Fig.  8y8. —{LamboUe.) 


When  one  bone  of  the  leg  or  forearm  is  the  site  of  pseudarthrosis  and  there 
is  much  loss  of  substance,  this  loss  must  either  be  made  good  or  apposition  of 


774 


UNUNITED    FRACTURE.       PSEUDARTHROSIS. 


the  fragments  obtained  by  excising  a  portion  of,  and  so  proportionately 
shortening  the  companion  bone.  For  example,  after  freshening  the  ends  of  the 
bone  in  pseudarthrosis  of  the  tibia,  direct  apposition  may  be  impossible  until 


Fig.  879. — (Lambotte.) 


Fig.  880. 


a  segment  of  the  fibula  is  excised.  Where  the  fracture  is  situated  in  the  lower 
third  of  the  radius  it  is  better  to  excise  a  portion  of  the  distal  end  of  the  ulna 
rather  than  a  segment  of  that  bone  opposite  the  radial  fracture.     By  doing  this 


PLASTIC    OPERATIONS. 


775 


the  necessity  of  obtaining  bony  union  of  a  new  fracture  is  avoided.  Such 
methods  are  easy  but  necessarily  entail  considerable  shortening,  hence  whenever 
possible  the  loss  of  substance  ought  to  be  made  good  by  some  plastic  operation. 
The  operative  treatment  of  certain  ununited  fractures,  such  as  those  of  the 
patella,  olecranon,  neck  of  femur,  etc.,  are  described  in  other  sections  of  this 
work. 


PLASTIC  OPERATIONS  ON  BONE. 

Plastic  operations  on  bone  are  required  to  stimulate  union  in  stubborn  cases 
of  pseudarthrosis;  to  fill  bony  defects  caused  by  the  destruction  or  excision  of 
segments  of  bone;  to  replace  bones  congenitally  absent  or  removed  by  operation. 


Fig.  88i. 


Fig.  882. 


Fig.  883. 


A 


(D 


B 


C 


Fig.  SS4. 

I.  Autoplasty  with  Pedunculated  Bone  Flaps.— i .  Oilier' s  operation  par 
renversement  may  be  taken  as  a  type  of  these  procedures.  Make  an  incision 
through  the  soft  parts  suffcient  to  expose  the  ends  of  the  bone  and  the  fibrous 
tissue  connecting  them.  Excise  the  fibrous  connection  between  the  fragments. 
With  a  fine  saw  cut  from  one  fragment  a  thin  slice  of  bone  along  the  line  a  b 
(Fig.  881)  and  remove  it.  From  the  point  c  on  the  other  fragment  cut  through 
the  bone  along  the  line  c  d,  leaving  the  periosteum  at  d  undivided.  The  wedge 
of  bone  d  c  f  can  now  be  turned  downwards  (using  the  perioseum  at  d  as  a  hinge) 
so  that  the  apex  of  the  wedge  can  be  wired  or  stitched  to  the  raw  bone  surface 


776 


UNUNITED    FRACTURE.    PSEUDARTHROSIS. 


a  b  (Fig.  882)  or  pushed  into  the  medulla.  In  young  and  vigorous  patients  the 
operation  has  proven  satisfactory.  As  much  as  two  inches  of  bone  may  be 
replaced  in  this  manner. 

2.  Ollier's  Operation  par  glissement. — From  one  of  the  fragments  cut  the 
triangle  C  (Fig.  883).  Be  careful  not  to  separate  this  portion  of  bone  (C)  from 
its  connections  with  the  soft  parts.  Slide  C  downwards  until  it  comes  in  contact 
with  the  fragment  D,  the  end  of  which  must  be  vivified.     Suture  C  to  D. 

3.  Ollier's  Implantation. — This  is  only  suitable  when  one  of  two  parallel 
bones  is  the  site  of  anchylosis. 

From  the  bone  A  cut  the  fragment  D  (Fig.  884)  preserving  its  connections 
with  the  soft  parts.  Vivify  the  fragments  B  and  C.  Implant  the  fragment 
D  between  B  and  C  (Fig.  885). 


Fig.  887. 

4.  W.  Miiller's  Operation. — Step  i. — Expose  the  ends  of  the  bone  by  a 
vertical  incision,  A  B  (Fig.'  886).  Remove  the  interposed  old  scar  tissue. 
With  a  chisel  vivify  the  ends  of  the  bone  (xx). 

Step  2. — Outline  the  flap  D  C  E  (Fig.  886).  With  a  chisel  introduced  at  C 
cut  a  slice  of  bone  from  the  upper  fragment,  thus  forming  a  flap  of  bone,  peri- 
osteum, and  skin,  which  has  a  pedicle  at  D  E. 

Step  3. — Rotate  the  flap  D  C  E  so  as  to  make  it  bridge  the  osseous  defect. 
Fix  the  osseous  surface  of  the  flap  to  the  vivified  ends  of  bone  fragments  at  xx 
(Fig.  887) ;  this  may  be  done  with  sutures  or  pegs. 

Step  4. — Close  or  lessen  the  size  of  the  defect  left  by  the  transplantation  of 
D  E  C  by  undermining  and  sliding  the  skin  edges  together  or  by  Thiersch's 
grafts. 


HUNTINGTON  S    METHOD. 


777 


5.  Miiller  has  devised  a  method  by  which  the  twisting  of  pedicle  of  the  flap 
is  avoided. 

Step  I. — Make  the  U-shaped  incision  A  B  C  D  (Fig.  888),  the  points  A  and  B 
being  an  inch  or  more  above  the  end  of  the  upper  fragments,  and  the  apex  of  the 
flap  (C  D)  a  similar  distance  below  the  end  of  the  lower  fragment. 

Step  2. — With  a  chisel  introduced  at  C  D,  cut  a  slice  of  bone  from  the  lower 
fragment  and  raise  it  along  with  the  corresponding  periosteum  and  skin. 
Continue  the  dissection  of  flap  A  B  C  D  upwards. 

Step  3. — Remove  the  fibrous  tissue  from  between  the  two  fragments  of  bone. 
With  the  chisel  vivify  the  end  of  the  upper  fragment  of  bone. 

Step  4. — With  the  part  of  flap  A  B  C  D  which  contains  bone  bridge  the  defect 
between  the  upper  and  lower  fragments  (Fig.  889). 


Fig.  888. 


Fig.  889. 


6.  Huntington's  Operation  ("Annals  Surg.,"  Feb.,  1905;  "California 
State  Journ.,"  Oct.,  1909). — Huntington's  operation  is  suitable  in  cases  where 
there  has  been  extensive  loss  of  the  tibia,  but  the  fibula  remains  intact.  It  is 
presupposed  that  any  infection  which  may  have  been  present  is  now  absent. 

Through  an  appropriate  incision  expose  and  divide  the  fibula  at  a  point 
opposite  the  lower  end  of  the  upper  tibial  fragment  and  fix  the  fibula  into  a 
depression  in  the  tibia.  Codman  ("Annals  Surg.,"  June,  1909)  carried  out 
Huntington's  operation  as  follows  (Figs.  890  and  891):  Make  a  curved  in- 
cision five  inches  in  length  across  the  leg  exposing  the  upper  fragment  of  the 
tibia.  Chisel  away  the  tip  of  this  fragment.  Divide  the  fibula  at  a  slightly 
higher  level.  Bend  the  leg  outwards  and  so  force  the  fibula  into  the  place  pre- 
pared for  it  in  the  upper  fragment  of  tibia  and  push  it,  like  a  peg,  for  a  short 


778 


UNUNITED    FRACTURE.       PSEUDARTHRCSIS. 


distance  into  the  spongy  bone.  Straighten  the  leg.  Fill  the  dead  space  left 
at  the  point  where  the  tibula  was  transferred  with  a  portion  of  tibialis  anticus 
muscle.  Close  the  wound.  Dress.  Immobilize.  In  time  there  is  liable  to 
be  a  bowing  of  the  foot  on  the  fibula  causing  a  deformity. 

This  led  Huntington  after  the  lapse  of  six  months  to  perform  a  second 
operation  as  follows:     Expose  the  upper  end  of  the  lower  fragment  of  tibia. 


Fig.  890. — Before  operation.  (Cod- 
man,  Annals  of  Surgery.) 


Fig.  291. — After  operation.     (Cod- 
man,  Annals  of  Surgery.) 


Vivify  it.  Divide  the  fibula  at  about  the  same  level.  Unite  the  fibula  to  the 
tibia.     Close  the  wound.     Dress.     Immobilize. 

Several  brilliant  results  have  been  obtained  by  Huntington's  operation. 
Huntington's  patient  walks  without  a  limp — -runs  and  plays  foot-ball. 

7.  J.  S.Stone^s  Operation  ("Annals  Surg.,"  Oct.,  1907). — Stone's  operation 
is  practically  identical  with  Huntington's  except  that  he  assures  stability  to 
the  foot  in  the  second  operation  by  having  both  malleoli  attached  to  the  new 
tibia  Fig.  892). 

First  Stage. — Implantation  of  the  upper  end  of  fibula  into  upper  tibial 
fragment.     Identical  with  Huntington's  operation. 


STONE  S    METHOD. 


779 


Second  Stage. — Expose  and  vivify  the  upper  end  of  the  lower  tibial  fragment. 
Expose  (without  injuring  the  periosteum)  the  lower  3  inches  of  the  fibula. 
Divide  the  periosteum  with  a  knife.     With  fine  chisel  and  strong  knife  split 


Fig.  892. — {Stone'),  Annals  of  Surgery. 

the  fibula  longitudinally  into  two  ec^ual  parts.  In  Stone's  case  "each  half  of 
the  bone  had  a  thickness  of  only  4  mm.,  scarcely  over  an  eighth  of  an  inch,  yet 
in  separating  them  for  a  distance  of  about  3  inches,  8  cm.,  it  was  essential 


780  UNUNITED    FRACTURE.      PSEUDARTHROSIS. 

that  the  periosteum  remain  adherent  to  each  portion  and  that  an  equal  thickness 
of  each  part  be  maintained  throughout.  It  was  planned  to  spread  the  halves 
without  breaking  either.  This  proved  impossible.  Fortunately  the  outer 
rather  than  the  inner  half  gave  way  close  to  the  upper  end  of  the  split  between 
them.  In  another  case  it  would  seem  wise  to  insure  a  break  in  the  outer  half 
at  this  point  rather  than  run  the  risk  of  breaking  the  inner  half  or  the  outer 
half  at  a  lower  level." 

When  the  fibula  has  been  transformed  to  take  the  place  of  the  tibia  its 
growth  becomes  much  increased  so  that  the  thin  splint-like  bone  comes  to  simu- 
late the  tibia  in  size. 

8.  Autoplasty  by  means  of  periosteal  flaps  (Codivilla's  operation)  is 
closely  allied  to  the  transplantation  of  pedunculated  flaps  of  bone.  Codivilla, 
after  vivifying  the  ends  of  the  bone,  unites  them  with  a  wire  suture  and  envelops 
this  suture  in  a  detached  flap  of  periosteum  taken  from  any  convenient  bone. 
Codivilla  is  careful  to  remove  a  thin  shell  of  bone  with  the  periosteum,  but 
Brade  ("Beitnige  zur  klin.  Chir.,"  Ixi)  used  the  periosteum  alone  and  obtained 
a  good  result. 

Operation  for  Congenital  Absence  of  Tibia. 

Halstead  Myers  ("Med.  Record,"  July  15,  1905)  operated  for  the  above- 
named  condition  successfully  as  follows:  Incision  across  the  outer  half  of  the 
joint  opening  the  articulation  between  the  fibula  and  femur.  The  patellar 
ligament,  thin  and  long,  was  inserted  on  the  inner  side  of  the  fibula  well  below 
its  head.  The  capsular  ligament  and  especially  the  external  lateral  ligament 
were  very  strong  and  required  division  before  the  head  of  the  fibula  could  be 
drawn  downwards  and  inwards  to  a  position  between  the  condyles.  The 
patellar  ligament  was  shortened  and  attached  to  the  anterior  surface  of  the 
fibula.  With  sutures  the  articular  capsule  was  repaired  so  as  to  aid  in  holding 
the  head  of  the  fibula  in  its  new  position.  After  closure  of  the  wound  at  the 
knee,  the  ankle  was  opened  by  a  transverse  incision,  the  external  malleolus  was 
cut  off  and  the  cut  end  of  the  fibula  planted  on  to  the  surface  of  the  astragalus 
which  was  denuded  for  that  purpose.  Apposition  of  the  bones  was  retained  by 
sutures.  The  after  treatment  consisted  in  immobilization.  A  year  after  opera- 
tion the  patient  could  flex  his  leg  to  go  degrees,  almost  fully  extend  it,  and 
walk  about  all  day. 

II.  Autoplasty  with  Non -pedunculated  Portions  of  Living  Bone. 

A.   Transplantation  of  portions  of  bone  covered  with  its  periosteum. 

Step  I. — Expose  the  ends  of  the  bone.  Remove  interposed  fibrous  tissue. 
Freshen  the  ends  of  the  fragments.     Temporarily  pack  the  wound. 

Step  2. — Select  the  bone  from  which  to  obtain  material  for  transplantation, 
the  favorite  ones  are  the  tibia,  the  ribs,  or  the  upper  third  of  the  ulna.  Make 
a  vertical  incision  down  to  the  bone  and,  without  disturbing  the  periosteum, 
expose  it  sufficiently.  With  a  chisel,  cut  away  a  slice  of  bone  with  its  periosteum 
large  enough  to  bridge  the  defect.     Pack  the  wound  temporarily. 

Step  3. — Remove  the  pack  from  the  wound  made  in  Step  i.     Bridge  the 


TRANSPLANTATION    BONE.  78 1 

osseous  defect  by  means  of  the  "bone-periosteal"  flap.  Be  sure  that  the  raw 
surface  (cut  surface)  of  the  graft  Hes  agamst  corresponding  raw  surfaces  in  its 
new  berth.  If  necessary  fix  the  graft  in  position  by  means  of  sutures.  Close 
the  wound.     Apply  dressings.     Immobilize. 

Step  4. — Remove  the  pack  from  the  wound  made  in  Step  2.  Close  the  wound. 
Apply  dressings. 

E.  Lexer  ("Archiv.  fiir  klin.  Chir.,"  Ixxxv,  939)  publishes  a  remarkable 
contribution  to  our  knowledge  of  bone  transplantation. 

In  his  clinic  amputation  for  dry  senile  gangrene  is  common  and  from  the 
limbs  so  amputated  he  obtains  his  material.  If  the  implant  is  to  be  covered 
by  periosteum  still  existing  around  the  bony  defect,  that  covering  the  implant 
must  be  removed,  as  a  double  layer  of  periosteum  gives  rise  to  exuberant  and 
irregular  development  of  bone.  In  all  other  circumstances,  even  when  the 
implant  is  placed  in  the  medullary  cavity,  the  periosteum  on  the  implant  should 
be  preserved.  If  a  tubular  or  cylindrical  bone  is  used  as  an  implant  and  the 
marrow  is  left  intact,  local  and  constitutional  disturbances  commonly  give 
trouble  without  infection  or  interference  with  union.  To  avoid  these  disturb- 
ances which  he  attributes  to  absorption  of  degenerated  medullary  substances, 
Lexer  removes  the  marrow  with  a  spoon  and  fills  the  resulting  cavity  with  an 
iodoform  plug  (like  Mosetig's). 

Lexer  has  successfully  implanted  segments  of  bone  (with  its  periosteum) 
8  to  12  inches  (20  to  30  cm.)  in  length.  The  bone  used  must  be  so  fresh  as  to 
be  still  warm. 

B.  Transplantation  of  part  of  the  ivhole  thickness  of  tJie  shaft  of  a  bone  plus 
one  of  its  articulating  ends. 

Transplantation  combined  with  arthroplasty. 

A  good  example  of  the  above  is  the  following:  In  a  case  of  sarcoma  of  the 
upper  end  of  the  humerus,  Rovsing  ("  Hospitalstidende,"  iii,  No.  i.  Ref. 
'■  Journ.  de  Chir.,"  March,  1910)  excised  the  diseased  bone  and  implanted 
a  segment  of  fibula. 

Step  I. — Make  a  curved  incision  following  the  borders  of  the  acromion 
process  and  through  this  penetrate  the  shoulder-joint.  Beginning  at  this  in- 
cision make  a  longitudinal  cut  down  the  outer  surface  of  the  arm  to  a  point 
well  below  the  disease. 

Step  2. — Excise  the  desired  portion  of  the  humerus  plus  its  periosteum  and 
the  muscular  insertions  so  as  to  keep  away  from  the  disease.  If  the  long  head 
of  the  biceps  is  involved  in  the  disease  excise  it  also. 

Step  3. — Attend  to  hasmostasis  and  pack  the  wound  temporarily  with  gauze. 

Step  4.— Expose  the  upper  end  of  the  fibula  through  a  longitudinal  incision, 
being  careful  to  retract  uninjuried  the  external  popliteal  nerve.  Open  the 
superior  tibio-fibular  articulation. 

Step  5. — Mobilize  a  segment  of  the  fibula  about  3  cm.  longer  than  the  seg- 
ment of  humerus  which  was  removed  and  excise  it  but  leave  "a  sort  of  muscu- 
lar sheath  about  i  cm.  thick  attached  to  it." 


782  UNUNITED    FRACTURE.       PSEUDARTHROSIS. 

Step  6. — With  a  chisel  sharpen  the  lower  end  of  the  fragment  of  fibula  and 
force  it  into  the  medullary  cavity  of  the  diaphysis  of  the  humerus. 

Step  7. — With  sutures  fasten  the  remains  of  the  articular  capsule  of  the 
shoulder-joint  to  the  fibula  and  the  soft  parts  of  the  arm  to  the  muscular  tissue 
left  attached  to  the  implanted  fibula. 

Step  8. — Close  the  wound.     Apply  dressings. 

In  Rovsing's  case  free  passive  motion  was  possible  two  months  after  opera- 
tion and  the  patient  was  able  to  use  the  arm  in  carrying  food  to  his  mouth. 

Operations  similar  to  or  identical  with  Rovsing's  have  been  performed 
by  a  number  of  surgeons. 

C.  Transplantation  of  fragmented  bone  with  or  without  periosteum. 
(Macewen's  method.) 

Step  I. — Expose  the  ends  of  the  bone.  Remove  interposed  fibrous  tissue. 
Freshen  the  ends  of  the  fragments.     Temporarily  pack  the  wound. 

Step  2. — Obtain  fragments  of  bone  as  in  method  A,  or  from  a  patient  on 
whom  cuneiform  osteotomy  is  necessary.  If  there  is  any  delay  between  obtain- 
ing the  fragments  and  their  implantation,  be  careful  to  keep  them  in  warm  salt 
solution  or  wrapped  in  warm,  moist  gauze.  With  a  chisel  cut  the  pieces  of 
bone  to  be  implanted  into  small  fragments. 

Step  3. — Fill  the  gap  between  the  freshened  ends  of  the  bone  to  be  united 
with  the  osseous  fragments  obtained  as  above. 

Step  4. — Close  the  wound  without  drainage.  Apply  dressings.  Immobilize. 
The  implantation  of  fragmented  bone  has  given  some  brilliant  results. 

III.  Transplantation  of  Dead  Bone. 

A.  Decalifiei  Bone  Chips. — On  the  theory  that  the  fragments  implanted 
according  to  the  preceding  method,  do  not  grow  but  merely  act  as  scaffolding 
to  be  replaced  by  osseous  material  supplied  by  the  ends  of  the  fractured  bone, 
some  surgeons  have  used  in  their  place  chips  of  decalcified  bone.  The  prepara- 
tion and  use  of  decalified  bone  chips  is  described  elsewhere. 

_B.  Transplantation  of  Large  Fragments  of  Dead  Bone. — Kausch  ("Beitrage 
z.  klin.  Chir.,"  Ixviii,  p.  670)  after  removing  the  upper  end  of  the  tibia  for 
sarcoma  implanted  a  corresponding  portion  of  a  tibia  obtained  in  the  course  of 
an  amputation  some  days  previously.  The  implant  was  deprived  of  its  peri- 
osetum  and  marrow,  was  carefully  boiled  and  soaked  in  ether  to  remove  its 
fat.  There  was  complete  operative  recovery  but  recurrence  of  the  sarcoma 
necessitated  amputation  nine  months  later  when  examination  showed  the 
implant  firmly  united  both  to  the  femur  and  the  tibia  and  enveloped  in  a  new 
formed  periosteum.  Kiittner  ("Zentralblatt  fur  Chir.,"  1910,  No.  31)  excised 
the  upper  third  of  the  femur  for  osteosarcoma,  and  at  once  implanted  a  similar 
portion  of  femur  obtained  from  a  man  who  had  been  operated  on  for  coma 
due  to  tumor  of  the  brain  and  died  without  regaining  consciousness.  The 
upper  end  of  the  femur  along  with  its  head  was  removed  under  aseptic  pre- 
cautions eleven  hours  after  death  and  was  preserved  for  twenty-four  hours  in 
salt  solution  to  which  some  chloroform  had  been  added.  Six  weeks  after 
operation  the  result  was  promising. 


CHAPTER  LXIX. 


FRACTURES.     MALUNIOR, 


When  fractures  have  soHcIly  united  in  bad  position  or  with  an  excess  of 
permanent  callus,  deformity  results.  The  deformity  is  often  of  no  importance 
but  when  it  is  disfiguring  or  disabling,  operation  may  be  proper;  when  it  is 
disabling  operation  may  be  obligatory. 

(A)  When  excessive  callus  causes  injurious  pressure  on  important  nerves 
or  vessels,  cut  down  upon  the  callus  and  with  a  chisel  or  rongeur  forceps  remove 


Fig.  893. 

as  much  of  it  as  may  be  necessary.  Sometimes  it  is  wise,  after  freeing  the  nerve 
or  vessel  from  injurious  pressure,  to  interpose  a  flap  of  fascia  or  muscle  between 
these  structures  and  the  bone. 

(B)  Malunion  without  much  shortening  but  in  a  more  or  less  angular  posi- 
tion requires  the  same  operative  treatment  as  similar  deformities  due  to  other 
causes.     See  Osteotomy. 

783 


784 


FRACTURES.      MALUNION. 


If  a  moderate  amount  of  shortening  is  present  an  oblique  osteotomy  will  not 
only  correct  the  angular  deformity,  but  may  permit  the  desired  amount  of 
lengthening  to  be  obtained  (Fig.  893). 


Fig.  894. 

(C)  Malunion  with  Much  Shortening 
Owing  to  "Overriding"  of  the  Bones. — The 
treatment  of  this  condition  consists  in  osteotomy, 
if  necessary  plus  fixation  of  the  bones  as  in 
pseudarthrosis.  Figures  894  and  895  sufficiently 
explain  the  general  plan  of  operation.  It  must 
be  remembered  that  contraction  of  the  soft  parts 
must  be  overcome  before  apposition  in  good 
position  can  be  obtained  or  maintained.  For 
this  purpose  extension  by  means  of  the  weight 


Fig.  896. 


Fig.  895. 


Fig.  897. — (Payr.) 


and  pulley  or  suitable  apparatus  is  often  sufficient,  but  it  must  frequently  be 
supplemented   by   tendon   lengthening,    by   tenotomies,    or   by   fasciotomies. 


MALUNION. 


78s 


Direct  Application  of  Extension  Apparatus  to  Bones. — Codivilla  and 
Steinmann  have  each  recommended  that  extension  be  appHed  direcdy  to  bones 


Fig.  898. — {Steinmann.) 

and  thus  better  results  be  obtained  than  where  the  ex- 
tension is  exerted  through  adhesive  plaster  applied  to 
the  skin.  The  application  of  the  principle  is  simple  and 
safe  provided  the  asepsis  is  perfect.  There  are  two 
methods  by  which  direct  extension  may  be  applied: 
I.  Make  a  puncture  down  to  the  bone.  Drill  a  hole 
completely  through  the  bone.  Introduce  a  skewer 
through  the  bone  and  make  it  protrude  through  a 
puncture  in  the  skin  on  the  opposite  side  of  the  limb. 
Apply  dressings  to  the  punctures,  around  the  protrud- 
ing ends  of  the  skewer.  Attach  strings  to  the  end  of 
the  skewer  and  a  weight  to  the  strings.  2.  On  one 
side  of  the  limb  make  a  puncture  down  to  the  bone 
through  the  puncture  fasten  a  nail  or  drill  securely  into 
the  bone.  Do  the  same  on  the  opposite  side  of  the 
bone  and  attach  weights  to  the  nails  by  means  of  cords 
(Figs.  896  and  897). 

Steinmann  has  devised  a  special  and  convenient  set 
of  instruments  for  carrying  out  the  procedure.  Figs. 
898  and  899  are  self-explanatory. 

It  may  be  useful  to  describe  in  some  detail  the  operative 

treatment  of  one  or  two  well-known  examples  of  malunion. 

I.  Malunion   in   Colles's   Fracture. — The  lower 

fragment  of  the  radius  is  tilted  dorsally  on  the  upper  fragment  and  has  become 

united  there,  causing  the  classic  "silver  fork"  deformity. 
50 


Fig.  899. — (Steinmann.) 


786 


FRACTURES.       MALUNION. 


Fig.  goo. 


Fig.  901. 


MALUNION. 


787 


Dawbarn's  Operation. — Step  i. — Expose  the  line  of  union  by  a  longitudinal 
incision  along  the  outer  side  of  the  bone.  Reflect  the  periosteum  along  with 
the  rest  of  the  parts  from  the  outer  side  of  the  bone.  Avoid  injuring  the 
radial  nerve. 

Step  2. — With  a  line  chisel  or  osteotome  divide  the  line  of  union  between 
the  two  fragments.  Correct  the  deformity  and  after  closing  the  wound  treat 
as  an  ordinary  Colles's  fracture.  After  correction  there  is  frequently  a  gap 
left  between  the  two  fragments.     This  gap  may  be  tilled  in  one  of  two  ways. 

Step  3. — (A)  At  a  point  midway  between  the  wrist  and  elbow,  make  an 
incision  down  to  the  ulna.  From  the  ulna  excise  a  segment  of  bone  equal  to 
the  gap  in  the  radius.  Unite  the  divided  ulna  secundem 
artem.  The  resultant  shortening  of  the  ulna  permits 
apposition  of  the  fragments  of  the  radius.  The  whole 
forearm  is  of  course  shortened. 

(B)  Remove  from  the  ulna  a  much  smaller  segment 
of  bone.  With  the  chisel  cut  this  segment  into  small 
fragments  and  implant  them  between  the  fractured 
surfaces  of  the  radius.  The  advantage  of  method  B  is 
that  there  is  less  shortening  of  the  forearm  than  with 
method  A. 

(C)  Possibly  the  gap  might  be  tilled  by  a  modifica- 
tion of  Ollier's  autoplastic  operation  (p.  775). 

Remarks. — H.  A.  Lothrop  (''Boston  Med.  and 
Surg.  Journ.,"  Dec.  7,  1905)  tinds  that  the  deformity 
from  unreduced  Colles's  fracture  can  usually  be  cor- 
rected by  manipulation,  under  an  anaesthetic,  during  the 
first  three  weeks  after  injury;  that  after  two  to  six 
months  an  operation  on  the  lines  of  Dawbarn's  should  always  improve  the 
position  and  frequently  the  function;  that  after  six  months,  while  it  is  easy  to 
correct  backward  and  upward  displacement,  lateral  displacement  is  hard  to 
overcome  and  usually  requires  osteotomy  of  the  ulna.  The  late  operation, 
according  to  Lothrop,  rarely  improves  function. 

II.  Malunion  after  Separation  of  Lower  Femoral  Epiphysis. — The 
epiphysis  is  usually  dislocated  forwards  and  upwards  and  remains  in  contact 
with  the  diaphysis.  There  may  be  much  callus.  Where  fair  mobility  of  the 
knee  is  retained  or  expected,  operative  reduction  is  positively  indicated;  where 
anchylosis  is  present  an  osteotomy  may  give  as  good  results  with  less  risk. 

(A)  Operative  Reduction. — Step  i. — Expose  the  line  of  union  by  a  long- 
itudinal incision  on  one  or  both  sides  of  the  limb. 

Step  2. — With  the  elevator  separate  the  periosteum  and  soft  structures 
together  from  the  sides  of  the  bone  at  the  line  of  union.  With  the  osteotome 
divide  the  line  of  union.  By  manipulation  reduce  the  fracture.  Before  obtain- 
ing reduction  it  may  be  necessary  to  pare  off  some  bony  prominences  or  ex- 
crescences and  to  divide  or  lengthen  the  hamstrings.     After  reduction  the  frag- 


FiG.  902. — {Feiss,  Surg- 
ery, Gynecology  and  Ob- 
stetrics.) 


788  FRACTURES.       MALUNION. 

ments  may  be  held  in  apposition  by  sutures,  nails,  bone  pegs,  or  buried  metallic 
splints. 

Step  3. — Close  the  wound  with  or  without  drainage.  If  a  tourniquet  (elastic 
constrictor)  has  been  used,  the  author  provides  drainage,  applies  dressings  and 
splint  and  only  removes  the  tourniquet  after  the  patient  has  been  put  to  bed 
with  the  limb  fixed  in  a  vertical  position.  After  twenty-four  hours  the  limb 
may  be  gradually  lowered. 

Figures  900  and  901  show  a  case  before  and  after  the  above  treatment  was 
carried  out. 

(B)  Osteotomy. — When  from  any  cause  operative  reduction  is  inappropri- 
ate, the  deforming  flexion  may  be  overcome  by  osteotomy. 

In  a  case  of  much  disability  due  to  malunion  after  Pott's  fracture,  Feiss 
("Surg.,  Gyn.,  Obst.,"  June,  1909)  corrected  the  deformity  and  restored  the 
weight-bearing  line  by  making  a  linear  osteotomy  on  the  tibia  and  a  cuneiform 
osteotomy  on  the  fibula,  Fig.  902  is  self-explanatory.  The  result  was  very 
gratifying. 


CHAPTER  LXX. 

SPECIAL  FRACTURES. 

I.  Fractures  of  the  neck  of  the  femur,  whether  involving  the  neck  alone  or 
with  it  the  trochanter. 

(A)  Excision  of  the  Head  or  Fragments. — Expose  the  joint  by  Hueter's 
anterior  incision  and  remove  the  fragments.  No  special  description  is  neces- 
sary. 

(B)  Nailing  the  Fragments  (Langenbeck,  Konig,  Trendelenburg,  etc.). — 
Step  I. — Make  a  short  vertical  incision  over  the  outer  surface  of  the  trochanter 
major  and  expose  the  bone. 


Fig.  903. 


Fig.  904. 


Step  2. — By  traction  reduce  the  fracture. 

Step  3. — With  a  drill  bore  a  hole  through  the  trochanter  and  into  that  part 
of  the  neck  attached  to  the  head.  Replace  the  drill  by  a  screw  nail  or  bone 
peg  (Fig.  903). 

Step  4. — Dress.  Apply  traction  and  immobilizing  apparatus.  (Note: 
Instead  of  the  screw  nail  or  peg,  the  Parkhill-Freeman  device  may  be  used.) 

(C)  Systematized  Operation. — Step  i. — From  a  point  midway  between 
the  trochanter  major  and  the  anterior  superior  spine  make  an  incision,  4  to 

789 


790 


SPECIAL    FILA.CTURES, 


6  inches  long,  downwards,  parallel  to  the  outer  margin  of  the  sartorius  muscle 
(Fig.  904)  (Hueter's  incision).  By  blunt  and  sharp  dissection  penetrate  to  the 
hip-joint  between  the  sartorius  and  the  tensor  vaginae  femoris  muscles.  A 
few  fibres  of  the  vastus  externus  require  division.     Remember  the  external 


—  Reflection  of  capsule 


Ligamentum  teres 


Fig.  905. 


MB 


{Morris.) 


Reflection  of  capsule 


/{[SULTAI^T 


circumtiex  artery  which  runs  transversely  immediately  below  the  trochanter. 

Step  2.— Retract  the  soft  parts.     The  fracture  will  now  be  visible.     Note 

that  the  capsule  of  the  joint  and  its  reflection  over  the  femoral  neck  are  torn. 

Remove  blood,  etc.,  from  the  woimd.     If  possible,  by  rotation  of  the  limb 

expose  the  capsule  posterior  to  the  joint  and 
repair  the  tear  in  it  with  sutures  (Fig.  905). 
Remember  that  the  most  important  portion 
of  capsule  reflected  on  the  femoral  neck  lies 
below  the  neck. 

Bring  the  fractured  surfaces  of  bone  into 
good  apposition  and  fix  them  in  position  (a) 
by  using  method  B  guided  by  the  finger  and 
eye  through  the  open  wound  (b)  by  means 
of  wire  sutures. 

Repair  the  tear  in  the  capsule  reflected  on 
to  the  neck  of  the  femur.  Repair  the  main 
rent  in  the  capsule.  Close  the  wound  in  the 
soft  parts. 

Step  3 . — Applying  dressings.  Immobilize. 
J.  E.  Moore  ("Northwestern  Lancet," 
March  i,  1904),  apropos  of  a  case  of  un- 
united fracture  on  which  he  operated,  remarks  that  the  nail  used  for  fixation 
might  have  been  omitted  with  advantage  and  the  Maxwell  method  of  exten- 
sion used  alone.  This  suggestion  applies  equally  to  cases  of  recent  fracture  of  the 
femoral  neck  whether  operated  on  or  not.     The  method  consists  in  applying 


Fig.  906. 


INTRACAPULAR  FRSACTURES. 


791 


extension  by  weight  and  pulley  in  the  directions  shown  in  figure  906,  the 
resultant  force  being  in  the  long  axis  of  the  neck  of  the  femur. 

Gurlt,  Fritz  Konig,  and  others  have  noted  that  in  true  intracapsular  fracture 
the  head  of  the  femur  deprived  of  nourishment  soon  undergoes  degenerative 
changes  which  unfit  it  for  union  even  after  operation,  hence  F.  Konig  advises 
operation  at  the  end  of  eight  days.  Fractures  of  the  neck  involving  the  tro- 
chanter rarely  require  operation.     Impacted  fractures  do  not  call  for  operation 


'mi^>'i^xd 


Fig.  907. — (Morris.) 
a.  Fat;  b,  Opening  in  synovial  membrane  behind  crucial  ligament  leading  into  inner 
half  of  joint;  c,  Synovial  membrane  reflected  otif  crucial  ligament;  d.  Cut  end  anterior  crucia 
ligament;  e,  Post,  crucial  ligament;/,  Oblique  popliteal  ligament;  g,  Quadriceps;  h,  Synovial 
sac;  i,  Tendon  quadriceps;  7,  Patella;  k,  Bursa;  /,  Condyle  femur;  m,  Patellar  synovialfold; 
n,  Fatty  cushion;  o,  Bursa;  p,  Tibia. 

unless  they  cause  disabling  deformity.  The  author  believes  operation  to  be 
rarely  indicated  in  fresh  fractures  of  the  femoral  neck.  Maxwell  and  Ruth's 
results  of  conservative  treatment  are  most  encouraging  ("Journal  Am.  Med. 
Association,"  April  9,  1904),  but  considering  how  badly  the  aged  bear  the 
necessary  confinement  in  bed,  the  writer  prefers  to  trust  to  massage,  and  almost 
immediate  passive  and  active  motion,  the  result  being  of  course  pseudarthrosis, 
but  almost  always  a  useful  limb. 

If  operation  is  chosen,  which  method  offers  most?  Method  B  means 
working  in  the  dark  and  entirely  neglects  restoration  of  the  joint  capsule  which 
has   a   most  important  influence   on  the  nutrition   of  the  head  of  the  bone. 


792 


SPECIAL  FRACTURES. 


Method  C  is  no  more  dangerous  than  methods  A  and  B,  but  permits  repair  of 
capsule.      One   of  F.    Konig's   cases    ("Archiv.  fiir  klin.  Chir.,"  Ixxv,  725) 
demostrates  admirably  the  importance  of  this  step.     Of  course  if  the  head  of  the 
bone  is  too  severely  injured  it  ought  to  be  removed. 
II.  Fractures  at  the  Lower  End  of  the  Femur. 

(A)  Transverse  Fractures. — Operative  treatment  is  practically  the  same 
as  that  for  separated  epiphysis. 

(B)  Separation  of  Lower  Femoral  Epiphysis. — Step  i. — As  the  knee- 
joint  is  usually  unopened  by  the  injury,  endeavor  to  avoid  penetrating  it. 
Figure  117  shows  the  normal  extent  of  the  synovial  sac.  "The  obstacle  to 
reduction  is  no  single  band  or  obstruction,  it  is  the  retraction  and  tension  main- 
tained by  the  fascia,  ligaments,  and  muscles  of  the  thigh  upon  the  tibia.  This 
retraction  is  so  great  that  the  tibia  is  held  crowded  against  the  lower  end  of  the 
upper  fragment,  and  prevents  the  replacing  of  the  epiphysis"  (Scudder). 


Fig.  908. — (Scudder.) 

Step  2. — Make  an  external  longitudinal  incision  freely  exposing  injured 
shaft  and  ep'physis. 

Step  3. — With  strong  hooks  make  traction  on  the  diaphysis  and  epiphysis 
(Fig.  908)  or  attain  the  same  purpose  by  other  means.  During  the  above 
manoeuvre  slowly  flex  the  knee  and  so  reduce  the  displacement. 

Step  4. — If  the  fragments  tend  to  remain  in  good  position,  pass  on  to  Step  5. 
If  the  fragments  do  not  tend  to  remain  in  good  position  apply  periosteal  suturse 
(good  in  any  case)  or  bone  pegs  of  any  or  the  established  means  of  fixation. 
It  is  more  important  to  avoid  irritating  means  of  fixation  in  case  of  epiphyseal 
separation  than  in  other  fractures  because  of  their  possible  evil  effect  on  subse- 
quent growth. 

Step  5. — Close  the  wound.  Apply  dressings.  Immobilize  for  three  or  four 
weeks  in  the  flexed  position.  After  this  time  the  leg  may  be  extended,  but  the 
use  of  plaster  of  Paris  or  splints  ought  to  be  kept  up  for  about  six  weeks  from 
the  date  of  operation. 

Figures  900  and  901  show  separation  of  the  femoral  epiphysis  before  and 
after  operation. 


PATELLA. 


793 


(C)  Fractures  of  the  Condyles  of  the  Femur. — A  small  amount  of  de- 
formity after  fractures  involving  the  knee-joint  means  much  disability,  hence 
operative  reduction  and  fixation  are  often  indicated. 

Step  I. — Expose  the  site  of  fracture  by  an  internal  or  external  longitudinal 
incision.     This  opens  the  joint. 

Step  2. — Reduce  the  fracture  and  fix  it  in  proper  position  by  some  of  the 
means  already  described.     The  author  prefers  bone  pegs. 

Step  3. — Remove  any  blood  and  detritus  which  may  be  present  in  the  knee- 
joint.     Close  the  wound  with  or  without  drainage. 

Step  4. — Dress.  Immobilize  in  the  extended  position.  Elevate  the  limb 
for  twenty-four  hours.  As  soon  as  possible  begin  massage  especially  of  the 
quadriceps  extensor  femoris. 


Fig.  909. 


Fig.  910. 


III.  Fracture  of  the  Patella. 

(A)  Subcutaneous  Methods  of  Fixation.  Barker's  Method. — Step  i. — 
Pass  a  long,  strong,  curved  needle  with  an  eye  near  its  point  through  the  skin 
and  tendo  patellce  immediately  below  the  lower  fragment.  Guide  the  point 
of  the  needle  upwards  through  the  knee-joint,  close  to  the  posterior  surface  of 
the  patella  and  make  it  emerge  immediately  above  the  upper  fragment  after 
passing  through  the  quadriceps  tendon  (Fig.  909). 

Step  2. — Thread  the  needle  with  a  strand  of  strong  soft  silver  wire.  With- 
draw and  unthread  the  needle. 

Step  3. — Through  the  same  opening  reintroduce  the  needle  and  pass  it 
upwards  close  to  but  in  front  of  the  patellar  fragments.  Make  it  emerge 
through  the  same  opening  above  (Fig.  910). 


794 


SPECIAL    FRACTURES. 


'S,tep  4.— Thread  the  needle  with  the  end  of  wire  protruding  through  the 

upper  opening  and  withdraw  it.     The  wire  now  surrounds  the  broken  bone. 

Step  5.— x\pproximate  the  fragments  of  bone.     Tighten  the  wire  and  twist 


Fig.  911. 


■VOl^ 


';^ 


Fig.  912. — {Aiter  Heifer ich.) 

its  two  ends  snugly.  Cut  off  the  excess  of  wire.  Bury  the  twisted  part  of  the 
wire  beneath  the  skin,  if  necessary  enlarging  the  original  needle  puncture  for 
this  purpose  with  a  knife. 


PATELLA. 


795 


A  modification  of  Barker's  method  is  as  follows:  Steps  i  and  2  as  above. 
Step  3 . — Approximate  the  fragments  of  bone.  Apply  a  firm  pad  over  the  patella. 
Bring  the  ends  of  the  wire  over  the  pad  and  twist  them  tight  (Fig.  911). 

(B)  Open  Operation. 

(i)  Classical  Operation. — Step  1. — Make  a  vertical  incision  in  the  middle 
line  from  a  point  about  one  inch  above  the  upper  fragment  to  a  similar  point 
below  the  lower  fragment.  Reflect  the  soft  parts  (exclusive  of  the  periosteum 
which  must  not  be  disturbed)  to  either  side  so  as  to  freely  expose  the  fractured 
surfaces. 

Step  2. — Remove  effused  blood  from  the  knee-joint  by  douching  with  salt 
solution  and  by  gentle  mopping  with  moist  gauze. 

Macewen  noted  ("Annals  Surg.,"  v,  177)  that  the  principal  obstruction  to 
bony  union  was  tags  of  torn  fascia  and  periosteum  which  curl  in  between  the 
fragments  and  become  fixed  to  the  fractured 
surfaces  by  becoming  impaled  on  the  pro- 
truding spiculas  of  bone  (Fig.  912).  Re- 
move all  interposed  tissue;  in  old  cases  of 
non-union  this  requires  that  the  surfaces  of 
the  bone  be  pared  or  freshened  with  the 
chisel  or  saw. 

Step  3. — With  a  drill  bore  two  sets  of 
holes  through  corresponding  parts  of  the 
upper  and  lower  fragments  without  en- 
croaching on  the  articular  surface  (Fig. 
913),  and  through  these  pass  sutures  of 
wire  or  chromicized  catgut.  It  is  easy  to 
pass  wire  through  the  holes  in  the  bone, 
but  when  pliable  material  or  catgut  is  used  it  is  well  to  use  a  drill  provided 
with  an  eye  or  notch  near  the  point  by  means  of  which  the  suture  may  be 
pulled  into  place  as  the  instrument  is  withdrawn. 

Step  4. — Reduce  the  fracture.  Tighten  and  fix  the  sutures.  If  wire  is 
used  after  it  has  been  fixed  by  twisting,  cut  off  any  excess  of  material  and  by 
hammering  flatten  the  projecting  knot.  If  the  case  is  an  old  one,  contracture 
of  the  quadriceps  may  so  interfere  with  approximation  as  to  require  lengthening 
of  the  muscle  or  tendon. 

Step  5. — Close  the  wound  in  the  soft  parts.  Apply  dressings.  Immobilize 
in  the  extended  position.     Elevate  the  limb  for  twenty-four  hours. 

(2)  Stimson's  Operation.  Mediate  Silk  Suture. — Steps  i  and  2  as  in 
classical  operation. 

Step  3. — With  a  full  curved  needle  pass  a  stout  silk  ligature  transversely 
through  the  ligamentum  patellae  close  to  the  apex  of  the  patella,  then  trans- 
versely in  the  opposite  direction  through  the  quadriceps  tendon  close  to  its  in- 
sertion.    Approximate  the  fragments  (Fig.  914).     Tighten  and  tie  the  suture. 

Step  4. — Place  one  or  two  catgut  sutures  in  the  torn  capsule  on  either  side. 


Fig.  913. 


796 


SPECIAL   FRACTURES. 


Step  5. — Close  the  wound.     Dress.     Immobilize. 

(3)  Vallas's  Operation.     Suture  of  Capsule. — This  operation  is  based 
on  the  fact  that  when  the  patella  is  fractured  transversely  there  can  be  but 


Fig.  gii^.—{Stimsan.) 


Fig.  915. 


Fig.    917. 


Fig.   916. 


Fig.  918. — (Labey.) 

little  separation  of  the  fragments  unless  the  fibrous  capsule  of  the  joint  (fibrous 
expansion  of  the  quadriceps;  capsular  ligament)  is  also  torn  (Fig.  915). 

Step  1. — Expose  the  fracture  as  in  the  classical  operation  by  a  vertical  inci- 


PATELLA. 


797 


sion.  A  more  generous  exposure  may  be  obtained  through  a  crucial  or  a  trans- 
verse incision  or  by  reflecting  a  U-shaped  flap  of  sldn  having  its  base  directed 
either  upwards  or  downwards.  The  writer  has  usually  employed  a  transverse 
incision,  but  the   imple  vertical  one  is  probably  sufficient. 

Step  2. — As  in  classical  operation. 

Step  3. — Carefully  inspect  the  torn  fibrous  capsule  on  either  side  of  the  patella. 


Fig.  919. — -(Labey.) 


Fig.  920. — -(Labey.) 


■If  necessary  trim  its  torn  edges.  With  catgut  close  the  wound  in  the  fibrous 
capsule  on  each  side  of  the  patella  (Fig.  916) ;  when  this  is  done  the  fragments  of 
bone  will  be  found  in  apposition  and  no  special  bone  sutures  will  be  required. 
Suture  the  torn  fascia  and  periosteum  over  the  patella.  Vallas  uses  the  trans- 
verse incision  and  silver  wire  U-sutures  for  the  capsule  which  are  removed  after 
eight  days.  A  glance  at  figure  917  shows  the  method  of  their  introduction 
("Rev.  de  Chir.,"  Oct.,  1899). 


Fig.  921. 


Fig. 


922. 


Step  4. — Close  the  external  wound.  Apply  dressings.  Immobilize  in  a 
position  of  extension. 

(4)  Purse-string  Suture  of  Patella.— Expose  the  bone  and  prepare  for 
union  as  already  described.  With  a  long  needle  (e.  g.,  Reverdin's)  make  a 
strong  silver  wire  encircle  both  fragments  of  the  patella  (Figs.  918,  919,  920). 
Approximate  the  fragments.     Tighten  and  fix  the  wire  by  twisting.     With 


798 


SPECIAL    FRACTURES. 


sutures  close  the  rent  in  the  librous  capsule  and  suture  the  fascia  and  periosteum 
over  the  patella.     Close  the  external  wound. 

(5)  Modified  Purse-string  Suture  of  Patella.  Quenu's  Operation.— 
This  is  suitable  when  one  of  the  fragments  is  much  smaller  than  the  other. 
Figures  921  and  922  sufficiently  describe  the  method. 

Fracture  of  the  Patella  with  Wide  Separation  of  the  Fragments. 
Lister's  Operation  in  Two  Stages. — Stage  1. — Make  a  short  longitudinal 
incision  over  each  of  the  fragments  (Figs.  923,  AB  and  CD). 


cC-^- 


Ai—^:B 


^^x> 


Fig.  923. — {Lister.) 

Step  2. — Drill  two  holes  in  the  upper  fragment  and  pass  the  ends  of  a  stout 
wire  through  them  from  without  inwards  (Fig.  924). 

Step  3. — By  blunt  dissection  make  a  tunnel  under  the  skin  from  the  lower 
incision  CD  to  the  upper  one  AB.  Pull  the  ends  of  the  wire  through  the  tunnel 
to  emerge  at  CD. 

Step  4. — Bore  two  holes  through  the  lower  fragment  of  the  patella  corre- 
sponding to  the  holes  bored  in  the  upper  fragment.  Pass  the  ends  of  the  wire 
through  these  holes  from  within  outwards  (Fig.  925). 

Step  5. — Flex  the  thigh;  extend  the  knee;  with  a  strong  sharp  hook  pull  the 


B»Wft;wo<gngff 


Fig.  924. — {Lister.) 


upper  fragment  of  the  bone  downwards;  tighten  the  wire  stitch  and  fix  it  by 
twisting.  Close  the  wounds.  Apply  a  posterior  splint.  Keep  the  limb  ele- 
vated (in  vertical  position  to  relax  the  quadriceps)  for  two  or  three  days.  Grad- 
ually lower  the  Hmb.  The  object  of  the  opera  ion  is  to  bring  the  fragments 
moderately  close  together — if  this  is  done  the  quadriceps  will  stretch  to  such  an 
extent  that  at  a  secondary  operation  the  broken  surfaces  of  the  patella  can  be 
freshened  and  brought  into  correct  apposition.  (The  diagrams  here  used  are 
reproductions  of  Lord  Lister's  rough  sketches  with  autograph  explanations 
("Brit.  Med.  Journ.,"  April  11,  1908). 


INDICATIONS. 


799 


Lynn  Thomas  attained  the  same  end  by  chiseling  the  tubercle  of  the  tibia 
from  its  seat,  being  careful  not  to  detach  the  tendinous  and  periosteal  attach- 
ments along  its  inner  edge.  Separation  of  the  tubercle  of  the  tibia  permits 
the  easy  approximation  of  the  fractured  surfaces  of  the  patella.  If  necessary 
the  tubercle  may  be  fixed  in  its  new  position  by  means  of  a  nail. 

Rotter's  Operation  ("  Zentralblatt  fiir  Chir.,"  1908, 
No.  17).— In  a  case  of  old  patellar  fracture  where  there 
was  much  separation  of  fragments  and  much  disability 
Rotter  operated  as  follows: 

(i)  Exposure  of  the  parts  by  means  of  a  curved 
incision. 

(2)  Excision  of  scar  tissue. 

(3)  Transverse  perforation  of  each  fragment  and 
introduction  of  a  wire  suture.  This  only  gave  a  slight 
degree  of  approximation. 

(4)  Formation  of  a  flap  from  the  aponeurosis  of  the 
rectus  femoris.  This  Hap  had  its  base  at  the  upper 
edge  of  the  upper  fragment  of  the  patella  and  was  long 
enough  to  reach  to  the  ligamentum  patellae. 

(5)  Application  of  the  fascial  flap  over  both  frag- 
ments of  patella  and  suture  of  it  to  the  ligamentum 
patellar  and  to  the  vivified  anterior  surfaces  of  the  bone 
fragments. 

(6)  Suture  of  the  wounds  in  the  capsule  of  the  joint. 
(To  the  author  this  seems  to  be  the  most  vital  step  in 
the  operation.) 

Immobilization  for  seventeen  days.  After  eight 
months  the  functional  result  was  good.  The  silver 
wire  was  found  to  have  broken. 

Occassionally  the  patella  will  be  so  comminuted 
in  an  open  fracture  that  its  repair  is  evidently  im- 
possible. Under  these  conditions  it  is  wise  to  remove 
all  the  fragments  and  detritus,  to  repair  all  injuries 
sustained  by  the  fibrous  capsule  of  the  joint  and  to 
put  the  patellar  periosteum  and  the  patellar  and 
quadriceps  tendons  in  as  favorable  a  condition  for 
repair  as  is  possible. 

Indications  and  Choice  of  Operation  in  Patellar 
Fracture. — i.    When   the   fragments  are  separated  as  much  as  one   linger 
breadth  (3/4  inch),  operate. 

2.  When  there  is  no  such  separation  or  examination  is  difficult  because  of 
pain  and  swelling,  keep  the  patient  in  bed,  apply  a  posterior  splint,  treat  the 
knee  with  elastic  pressure  and  massage.  After  about  one  week,  proper  examina- 
tion will  be  possible.     Ask  the  patient  to  lift  his  heel  up  from  the  plane  of  the 


':i 


-< 


8oo 


SPECIAL    FRACTURES. 


bed  to  the  slightest  extent  and  not  more.     If  he  can  do  this,  operation  is  unneces- 
sary; if  he  cannot,  then  operate. 

3.  The  best  time  to  operate  is  during  the  second  week  after  injury. 

4.  None  of  the  subcutaneous  operations  permit  removal  of  fascia  from 
between  the  fragments,  nor  do  they  repair  the  injured  and  important  fibrous 
capsule,  hence  they  are  objectionable. 

5.  All  the  methods  in  which  material  which  might  prevent  union  is  removed 


Fig.  926. 

and  in  which  the  torn  fibrous  capsule  is  repaired  are  satisfactory.  The  author 
prefers  Vallas's  operation. 

6.  When  the  bone  is  much  comminuted,  the  purse-string  suture  may  be 
the  most  suitable. 

After-treatment. — About  two  weeks  after  operation  begin  massage  of  the 
thigh.  Encourage  the  patient  to  contract  the  quadriceps  muscle,  without, 
however,  doing  it  to  such  an  extent  as  to  cause  pain  or  jeopardize  union.     About 


Fig.  927. 

hree  weeks  after  operation  begin  massage  of  the  whole  limb,  use  passive,  and 
later  active  motion. 

IV.  Fracture  of  Tubercle  of  Tibia.* — When  the  tubercle  of  the  tibia 
is  torn  from  the  bone  it  may  be  pulled  upwards  a  distance  of  four  inches;  but 
this  is  exceptional,  about  two  inches  being  the  usual  displacement.  With  the 
tubercle  a  portion  of  the  tibial  cortex  may  be  torn  off  and  this  may  remain 

*  For  a  full  discussion  of  the  accident  and  its  treatment  see  Gaudier  and  Bouret,  "Rev. 
de  Chir.,"  Sept.,  1905. 


OS    CALCIS;   HUMERUS. 


8oi 


more  or  less  attached  by  its  upper  end  to  the  articular  surface  of  the  bone. 
The  fractured  fragment  of  bone  may  become  wedged  into  the  knee-joint 
(Fig.  926). 

Operative  Treatment. — Step  1. — Freely  expose  the  site  of  injury  by  a 
vertical  or,  better,  by  a  horseshoe-shaped  incision  having  its  base  above.  If 
the  knee-joint  is  invloved,  wash  all  blood-clots,  etc.,  out  of  it. 

Step  2. — Reduce  the  fracture.  To  do  this  satisfactorily  it  may  be  necessary 
to  pass  a  strong  suture  transversely  through  the  tendo  patellae  as  a  tractor. 
The  suture  may  be  eventually  used  as  a  means  of  fixation  by  passing  it 
through  a  hole  bored  in  the  tibia. 

Step  3. — Unite  the  fractured  tubercle  to  the  tibia  by  means  of  periosteal 
sutures  or  of  bone  pegs,  nails,  or  a  wire  suture  (Fig.  927).  If  the  knee-joint  is 
open,  close  it  with  sutures. 

Step  4. — Close  the  external  wound  with- 
out drainage.  Dress.  Treat  like  fractured 
patella. 

V.  Fracture  of  Tuberosity  of  Os 
Calcis. — This  fracture  almost  always  re- 
quires fixation  by  operation. 

Method  A. — Reduce  the  fracture  by 
manipulation.  Make  a  very  small  incision 
(puncture)  down  to  the  middle  of  the 
posterior  surface  of  the  fragment  of  bone 

attached  to  the  tendo  Achillis.  Drill  a  hole  through  the  fragment  and  into  the 
body  of  the  os  calcis.  Substitute  a  nail  or  a  bone  peg  for  the  drill  (Fig.  928). 
If  necessary,  close  the  skin  wound  with  a  stitch.  Immobilize  in  a  position  of 
plantar  flexion  with  the  knee  flexed. 

Method  B. — Is  the  same  as  A  except  that  the  site  of  injury  is  exposed  by 
turning  down  a  flap  of  skin,  with  its  convexity  upward.  Cheyne  and  Burghard 
advise  that  "the  flap  should  reach  high  enough  up  the  back  of  the  ankle  to 
escape  friction  from  the  hard  part  of  the  boot."  In  old  cases  it  may  be  neces- 
sary to  lengthen  the  tendo  Achillis  before  reduction  is  possible. 

VI.  Fractures  of  the  Upper  End  of  Humerus.— Non-impacted  fractures 
of  the  anatomical  neck  of  the  humerus  rarely  result  in  bony  union,  because  of 
malnutrition.  If  good  apposition  cannot  be  obtained  (as  shown  by  Skiagraphy) 
the  best  treatment  is  to  excise  the  head  of  the  bone  through  an  incision  along 
the  anterior  border  of  the  deltoid.  It  may  be  well  to  supplement  the  excision 
by  enveloping  the  fractured  surface  of  the  upper  end  of  the  humerus  in  a  flap 
of  fat  and  fascia  so  as  to  insure  as  much  as  possible  against  anchylosis.  Frac- 
tures of  the  surgical  neck  and  those  through  the  neck  and  the  tuberosities 
are  to  be  treated  by  operation  when  the  X-ray  demonstrates  the  futility  of 
conservative  measures. 

Occasionally  the  greater,  rarely  the  lesser,  tuberosity  is  in  whole  or  in  part 
detached  from  the  humerus.     Fritz  Konig  believes  the  accident  much  more 
51 


802 


SPECIAL    FRACTURES. 


common  than  is  usually  supposed  as  an  accompaniment  of  luxations  and  of 
fractures  through  the  tuberosities.  To  diagnose  it  accurately  necessitate  the 
taking  of  skiagraphs  before  reduction  of  the  dislocation  (Figs.  929  and  930). 
Non-operative  treatment  Konig  finds  very  unsatisfactory. 

Methods  of  Operating. — (A)  Fracture  of  surgical  neck;  oblique  fracture 
through  tuberosities;  separation  of  epiphysis. 

Step  I. — Make  a  free  incision  in  the  interval  between  the  deltoid  and  pec- 
toral. Doubly  ligate  or  displace  the  cephalic  vein.  Penetrate  between  the  two 
muscles.  Retract  the  deltoid  strongly,  if  necessary  dividing  a  few  fibres  at  its 
insertion.     Expose  the  fracture. 


Fig.  929. — (Konig.) 

Step  2. — Inspect  the  fracture.  Remove  interposed  tissues.  Reduce  by 
traction  and  manipulation.  If  the  head  is  dislocated,  it  may  be  necessary  to 
bore  a  hole  in  it  and  insert  McBurney's  hook  as  a  tractor. 

Step  2)-- — Fasten  the  fragments  together  by  means  of  sutures  (wire,  catgut, 
etc.),  pegs,  nails,  staples,  etc.,  as  may  be  convenient. 

Step  4. — Suture  the  torn  periosteum  with  fine  catgut.  Close  the  wound, 
obliterating  dead  spaces. 

Step  5. — Dress.  Treat  as  a  simple  fracture.  Begin  passive  motion  after 
about  two  and  one-half  weeks. 

(B)  Fracture  of  the  Tuberosity  of  the  Humerus. — Step  i. — Exposure  of 
the  fracture. 

(a)  Cheyne  and  Burghard  recommend  that  a  flap  containing  the  deltoid 
be  turned  up,  the  deltoid  being  divided  near  its  insertion. 

(b)  Make  the  incision  recommended  for  fracture  of  the  surgical  neck  and 
by  retracting  the  deltoid  expose  the  tuberosity. 

Step  2. — Fix  the  detached  tuberosity  in  place  by  suture  or  pegs.     If  it  is 


HUMERUS. 


803 


difficult  to  insert  the  peg  through  the  incision  b,  guided  by  the  view  obtained 
through  that  incision,  make  a  puncture  through  the  soft  parts  directly  over  the 
replaced  tubercle  and  through  this  insert  a  peg  or  nail. 

Step  3. — Suture  the  torn  periosteum.  Close  the  wound.  Dress.  Treat  as 
a  simple  fracture. 

VII.  Fractures  of  the  Lower  End  of  Humerus. — If  the  position  of  acute 
flexion  (Jones's  position)  be  adopted  for  all  fractures  of  the  lower  end  of  the 
humerus  operation  vdll  rarely  be  necessar}^  The  fractures  which  very  commonly 
require  intervention  are  separation  of  the  capitellum  humeri  and  fracture  of 
the    internal    epicondyle  when  there  is  much  separation.     The  opinions  of 


Fig.  930. — (Konig.) 

surgeons  vary  much  as  to  operative  interference.  Cheyne  and  Burghard  recom- 
mend operation  almost  as  routine  in  T-fractures.  Of  course  when  there  is 
grave  injury  to  the  nerves  (usually  the  musculo-spiral  and  median)  or  to  the 
vessels  about  the  elbow  a>^d  this  is  not  relieved  by  reposition  of  the  fragments 
of  bone,  operation  is  imperative. 

When  operating  if  it  is  possible  to  avoid  opening  the  elbow-joint,  do  so. 
Figure  931  shows  the  limits  of  the  joint.  The  time  of  choice  for  operation  is 
during  the  second  week  after  injury.  After  operation  passive  movements 
ought  to  be  begun  in  about  fourteen  days  or  even  less. 

Methods  of  Operating. — (A)  Fracture  of  one  condyle. 

Step  I. — Reflect  a  skin  flap,  convexity  forwards,  from  over  the  fractured 
condyle  (Cheyne  and  Burghard). 

Step.  2. — ^Flex  the  elbow.  Separate  the  soft  parts  from  the  upper  part  of 
the  condyle  until  there  is  sufficient  exposure.  Remove  interposed  tissues  and 
wash  the  joint  cavity  with  salt  solution. 

Step  3. — Reduce  the  fracture  and  fix  it  in  position  by  peg,  nail,  or  suture. 
Suture  any  important  structures  which  may  have  been  torn  or  divided. 


8o4 


SPECIAL    FRACTURES. 


Step  4. — Close  the  wound.  Dress.  J'ut  up  in  the  acutely  flexed  position. 
No  splint  is  necessary  or  desirable. 

(B)  Fracture  of  Both  Condyles.     T-shaped  Fracture. 

Step  I. — ^Method  A. — Make  a  longitudinal  lateral  incision  over  each  con- 
dyle and  expose  the  fracture.  Do  not  jeopardize  the  nutrition  of  the  condyle 
by  unnecessary  separation  of  the  soft  parts. 

Method  B. — Make  a  vertical  median  incision  over  the  olecranon  process  as 
in  excision  of  the  elbow.  Split  the  triceps  tendon  vertically.  With  the  periosteal 
elevator  separate  the  tendon  from  the  ulna  and  so  reach  the  fracture  without 
peeling  the  condyle  out  of  its  attached  soft  parts. 


Radial  cul  de  sac. 
Fig.  931. —  (Poirler  et  Charpy.) 


Step  2. — Reduce  the  fracture.  Peg  the  two  condyles  together  or  to  the 
shaft  of  the  humerus.  If  incision  B  has  been  used,  it  is  well  after  reducing  the 
fracture  to  make  a  puncture  direcdy  over  the  tip  of  the  condyle  and  introduce 
the  pegs  through  this  puncture. 

Step  3.— Close  both  deep  and  superficial  wounds.  Dress.  Put  in  acutely 
flexed  position  without  a  splint. 

(C)  Separation  of  Capitellum  Humeri.— Open  the  joint  by  an  external 
longitudinal  incision.  Remove  the  fragment  of  bone.  Close  the  wound. 
Dress.     Begin  motion  within  a  few  days. 

(D)  Fracture  of  Internal  (or  External)  Epicondyle.— (a)  Make  a 
lateral  longitudinal  incision  over  the  fragment  of  bone  without  opening  the 
joint.  Replace  the  fragment  and  suture  it  in  position.  The  suture  involves 
the  periosteal  covering  or  may  include  the  cartilaginous  epicondyle  itself. 


HUMERUS. 


805 


If  the  displaced  fragment  is  very  small  or  if  (in  an  old  case)  it  has  become 
fixed  in  a  position  which  interferes  -with  the  elbow,  excise  it  and  suture  the 
lateral  ligament  in  proper  position.     Dress.     Begin  motion  at  an  early  date. 


Fig.  932. — (Lambolle.)  Fig.  933. — (Lambotte.)  Fig.  934. — [Lamhotte. 


Fig.  935. — {Lambotte.)  Fig.  936. — {Lambotte.)  Fig.  937. — {Lambotte. 


Fig.  938. — {Lambotte,)  Fig.  939. — (Lambotte.) 

a,  Point  of  insertion  of  screw  into  trochlea. 
b.  Point  for  nailing  epitrochlea. 


The  following  figures  taken  from  Lambotte  (L'Intervention  Operatoire  dans 
le  Fractures)  show  the  application  of  screw  nails  to  several  varieties  of  fracture 
at  the  elbow  (Figs.  932-939). 


8o6 


SPECLAL    FRACTURES. 


\'I11.  Fracture  of  Olecranon  Process. — Most  cases  of  the  above  fracture 
call  for  operation. 

(A)  Subcutaneous  Operation,  Murphy's  Method. — Step  i. — Make  a 
longitudinal  incision  1/3  inch  long  on  the  outer  side  of  ulna  down  to  the  bone, 
1/2  inch  from  the  articular  surface  (A,  Fig.  940).  Make  a  corresponding  but 
smaller  incision  on  the  inner  side  (B).  Between  these  two  cuts  perforate  the 
ulna  and  pull  a  wire  through  the  drill  hole.  With  an  appropriate  needle  carry 
the  wire  under  the  skin  upwards  on  the  inner  side  of  the  elbow  and  draw  it 
out  through  a  puncture  wound  at  the  level  of  the  tip  of  the  olecranon  (C)  (the 

tip  of  the  olecranon  having  been  brought 
down  into  proper  position  by  manipulation). 

Step  2. — With  an  appropriate  needle  pass 
the  lA-ire  through  the  same  (upper)  puncture 
transversely  through  the  triceps  tendon  imme- 
diately above  the  fragment  of  olecranon  and 
make  it  emerge  through  a  puncture  wound 
(D)  on  the  outer  side.  Once  more  reintroduce 
the  ^^^re  and  make  it  emerge  at  the  original 
incision  (A).  The  site  of  fracture  is  now  en- 
circled by  the  wire. 

Step  3. — Tighten  and  twist  the  wire.  Cut 
off  the  ends  and  bury  the  knot.     Dress. 

Murphy  recommends  immobilization  in 
the  extended  position  for  4  weeks,  with  passive 
motion  from  the  third  day.  Che}Tae  and 
Burghard  recommend  that  the  elbow  be  kept 
at  a  right  angle  in  a  sling  and  that  early  motion 
be  attempted.     This  advice  seems  very  rational. 

(B)  Open  Operation. 

Step  I. — Method  of  Exposure. — (a)  Make  a  median  longitudinal  incision 
from  a  point  3/4  inch  above  the  tip  of  the  fractured  olecranon  downwards 
to  a  point  near  the  base  of  the  olecranon.  Divide  the  skin  and  superficial 
fascia  only.  Reflect  the  soft  parts  to  either  side  until  the  bone  covered  by 
deep  fascia,  etc.,  is  well  exposed. 

(b)  Make  a  horseshoe-shaped  incision  through  the  skin  and  superficial 
fascia  from  a  point  just  below  the  line  of  fracture  on  one  side  to  a  corresponding 
point  on  the  other  side.  The  cut  runs  upwards  to  a  point  about  i  inch  above  the 
tip  of  the  olecranon  (Fig.  941).     Reflect  the  flap  thus  outlined. 

(c)  Same  as  (b)  except  that  the  base  of  the  flap  is  above  instead  of  below. 
Step    2. — Examine    the    fractured    surfaces.     Remove    interposed    tissues. 

In  old  cases  freshen  the  ends  of  the  bone.     If  necessary  cleanse  the  joint 
cavity. 

Step  3. — Suture  of  the  Bone. — (a)  With  a  drill  make  one  or  two  oblique 
perforations  through  the  upper  and  lower  fragments  at  corresponding  points. 


Fig.  940. 


OLECRANON. 


807 


Pull  wire  through  the  perforations  (Fig.  942).  Do  not  let  the  deep  part  of  the 
perforation  impinge  upon  the  articular  surface  of  the  bone.  Wliile  boring 
the  holes  flexion  of  the  arm  permits  more  easy  access.  Now  extend  the  arm. 
Approximate  the  fragments.     Tighten  the  \\are  sutures  and  fix  them  by  twisting. 


Fig.  941. 


Fig.  942. 


Hammer  the  wire  knots  flat  or  into  the  bone  so  that  they  may  not  injure  the 
skin  subsequently.     Instead  of  wire,  chromicized  catgut  may  be  used. 

(b)  Circular  Suhire. — With  a  drill  make  a  perforation  transversely  through 
the  olecranon  about  1/2  inch  from  the  fractured  surface  (Fig.  943).     Pull  a 


Fig.  943. — {Schwartz.) 


Fig.  944. —  {Schwartz.) 


wire  through  the  perforation.  In  the  same  manner  drill  a  transverse  hole 
through  the  detached  portion  of  the  olecranon  and  pull  one  end  of  wire  above 
mentioned  through  it.     Approximate  the  fragments.     Tighten  and  fix  the  wire. 


8o8 


SPECIAL    FRACTURES. 


(c)  Is  the  same  as  (b)  except  that  the  upper  loop  of  wire  perforates  the 
triceps  tendon  instead  of  the  bone.  Instead  of  wire,  chromicized  catgut  may 
be  employed. 

Step  4. — With  fine  catgut,  suture  the  joint  capsule  (Fig.  944)  and  the  fascia 
covering  the  olecranon.  Close  the  skin  wound.  Dress.  The  limb  may  be 
immobilized  either  in  the  extended  or  semiflexed  position  or  may  be  put  in  a 
sling.  However  dressed,  passive  motion  must  be  begun  very  early  to  insure 
good  results. 

^Any  of  the  methods  of  operating  described  give  good  results. 


Fin.   945. — (Keen.) 


IX.  Fracture  of  Coronoid  Process  of  Ulna. — This  fracture  is  rare  and 
when  present  is  usually  associated  with  posterior  dislocation  of  the  elbow. 
As  the  brachialis  anticus  is  attached  near  the  base  of  the  coronoid,  there  is 
not  much  displacement  unless  this  part  of  the  bone  is  involved.  Operation 
must  be  very  rarely  indicated  except  in  old  cases  with  disability  due  to  inter- 
ference with   tlexion. 

Step  I. — Exposure  of  Coronoid  Process. — Make  a  lateral  incision  on 
one  or  each  side  just  in  front  of  the  condyles  of  the  humerus.  With  a  periosteal 
elevator  separate  the  muscle  from  the  anterior  surface  of  the  condyles  until 


HEAD    R.\DIUS. 


809 


the  brachialis  anticus  and  with  it  the  coronoid  process  is  exposed.     Subsequent 
work  is  much  facihtated  if  the  process  is  exposed  from  both  sides.  • 

Step  2. — Repair  whatever  injur\'  is  found.  Usually  operation  is  performed 
late  because  of  disability  due  to  excessive  callus  or  to  the  formation  of  bone 
in  the  tendon  of  the  brachialis  anticus  (practically 
myositis  ossificans  traumatica).  \\Tien  this  is  the  case 
remove  the  excess  of  bone. 

Step  3. — Close  the  wound.  Dress.  Apply  a  sling. 
Begin  motion  early. 

N.  B. — The  above  description  is  based  on  that  of 
Cheyne  and  Burghard.  The  author  has  never  seen  a 
case  of  fracture  of  the  coronoid  process  requiring 
operation.  He  has,  however,  seen  one  or  more  cases 
of  myositis  ossificans  traumatica  which  perhaps  might 
have  been  mistaken  for  such  a  condition  and  in  which 
the  neoplastic  bone  was  removed  through  an  external 
incision  penetrating  the  muscle  (Fig.  945). 

X.  Separation  of  Head  of  Radius. — Operation  is 
required  when  the  head  of  the  radius  has  become 
separated  from  the  shaft  and  lies  in  the  elbow-joint 
impeding  motion. 

Step  I. — Make  a  three-inch  longitudinal  incision  as  in  figure  946.  Separate 
the  anconeus  and  extensor  carpi  ulnaris  muscles.  This  exposes  the  head  of 
radius. 

Step  2. — Incise  the  articular  capsule.  Remove  the  fragment  of  bone. 
Close  the  wound  with  deep  and  superficial  sutures.  Dress.  Put  in  sling. 
Begin  motion  very  early. 


Fig.  946. 


CHAPTER  LXXI. 
OSTEOMYELITIS. 

As  the  result  of  infection  acute  inflammation  develops  in  the  vascular 
spongy  bone  usually  near  an  epiphysis.  Pus  quickly  forms  and,  if  the  patient 
survives  long  enough,  makes  its  way  to  the  periosteum  and  soft  parts.  When 
the  pus  escapes,  fistulas  are  formed  and  persist.  Early  death  of  portions  or 
even  the  whole  of  the  bone  is  a  prominent  feature  and  aids  in  keeping  up  the 
inflammation.  In  time  new  bone  is  formed  which  incloses  the  dead  portions 
(sequestra),  keeps  up  the  continuity  of  the  bone,  but  prevents  the  escape  of 
the  sequestra  when  they  become  separated  from  the  living  bone  by  the  activity 
of  granulation  tissue  growth. 

From  the  above  it  is  evident  that  different  methods  must  be  taken  to  com- 
bat the  disease  according  to  the  stage  to  which  it  has  developed.  When 
operating  for  osteomyelitis  of  one  of  the  bones  of  an  extremity,  it  is  wise  to 
secure  a  bloodless  field  by  using  an  elastic  constrictor,  as  it  is  very  important 
to  see  clearly  in  order  to  judge  how  much  it  is  necessary  to  do.  In  the  succeed- 
ing paragraphs  operations  for  osteomyelitis  of  the  lower  femoral  juxta- 
epiphyseal  bone  will  be  taken  as  typical. 

(A)  Early  Operation. — The  patient,  usually  young,  may  have  sustained  a 
slight  injury  or  been  exposed  to  cold;  or  the  patient  may  recently  have  suffered 
from  an  acute  disease;  there  is  much  prostration;  pain  near  the  knee,  often 
thought  to  be  in  the  knee ;  there  has  been  a  chill  and  high  fever  often  mistaken 
for  typhoid;  there  is  evidently  a  serious  illness,  often  delirium  is  present. 
Locally  the  only  symptoms  may  be  pain  and  tenderness;  this  last  is  our  only 
guide  to  the  seat  of  disease.  Commonly  at  this  period  there  is  some  swelling 
as  well  as  pain. 

The  Operation. — Before  anaesthetizing  the  patient  locate  the  point  of 
maximum  tenderness;  this  is  the  place  to  be  exposed  by  operation. 

Step  I. — Make  a  free  longitudinal  incision  down  to  the  bone  on  the  outer 
or  inner  side  of  the  thigh  as  may  be  convenient  so  as  to  avoid  injury  to  im- 
portant structures  and  yet  reach  the  point  of  maximum  tenderness  as  directly 
as  possible.  The  best  incision  is  one  on  the  outer  side  situated  in  the  furrow 
between  the  biceps  tendon  and  the  ilio-tibial  band  (Fig.  947)-  Note  the 
condition  of  the  divided  tissues  as  to  oedema,  etc.  Split  the  periosteum  over 
the  suspected  area  of  bone.  Note  the  condition  of  the  periosteum  as  to  thick- 
ness, softness,  oedema,  etc.,  and  as  to  the  firmness  or  looseness  of  its  attach- 
ment to  the  bone. 

Separate  the  periosteum  from  the  bone  over  an  area  about  1/2  inch  in 

810 


OSTEOMYELITIS. 


8ll 


diameter.  Examine  the  surface  of  the  bone  for  evidences  of  disease.  Pass 
a  grooved  director  round  the  bone  to  the  popliteal  surface  of  the  bone  as  pus 
from  the  osteomyelitis  often  collects  here.  In  our  example,  no  such  evidence 
may  be  discovered. 


Gluteal  sulcus 


Tensor  fasciae 
latae 


-     Ilio-tibial  band 


•-Popliteal  fascia 


Fig.  947. — (Sabotta.) 

Step  2.— With  a  Doyen  burr  (Fig.  948),  a  small  trephine,  or  a  gouge  and 
mallet,  penetrate  the  bone  to  the  medulla  or  into  the  spongy  bone  near  the 
epiphyseal  lin-  (a  drill  or  gimlet  is  often  used  to  penetrate  the  bone,  but  the 
resulting  opening  is  too  small  to  permit  of  proper  investigation).     It  may  not 


8l2 


OSTEOMYELITIS. 


be  necessary  to  penetrate  the  bone  very  deeply  as  the  focus  of  disease  may  be 
found  fairly  superiicial.  The  diseased  area  may  be  recognized  by  its  redness, 
the  presence  of  granulation  tissue,  a  decrease  in  the  consistency  of  the  tissue, 
decrease  in  the  amount  of  fat,  and  by  the  presence  of  a  small  amount  of  pus. 
Many  surgeons,  especially  in  Paris,  consider  that  it  is  not  possible  to  dis- 
tinguish clinically  in  all  cases,  acute  suppurative  osteomyelitis  from  periostitis 
and  hence  consider  it  harmful  to  systematically  attack  the  l)one  since  simple 
periosteal  incision  may  suffice.  S.  Rolando  ("Zentralblatt  ftir  Chir.,"  1908, 
No.  20)  has  had  much  experience  in  hematogenous,  osteomyelitis  and  finds 
that  the  periostitis  is  always  secondary  to  the  osteomyelitis.  To  avoid  un- 
necessarily extensive  opening  of  the  bone  Rolando  is  guided  by  radiography 


Fig.  948. 


and  only  opens  the  bone  itself  at  places  where  clear  zones  indicate  the  presence 
of  lesions.  Rubritius  ("Zentralblatt  fiir  Chir.,"  1908,  No.  9)  thinks  radio- 
graphy valueless  in  recent  cases.  Multiple  openings  into  the  bone  may  be 
required.  It  is  unnecessary  to  expose  the  whole  of  the  medullary  cavity  as  is 
done  by  some.  All  that  is  recjuisite  is  to  penetrate  the  foci  at  the  most  depen- 
dent points  possible,  to  evacuate  their  contents  and  to  prevent  reaccumulation. 
Step  3. — Thoroughly  remove  all  the  diseased  material  with  a  sharp  spoon, 
aided  if  necessary  by  a  gouge.  Wash  or  douche  the  cavity.  Swab  with 
Harrington's  solution,  with  tincture  of  iodine,  or  with  liquid  carbolic  acid, 
subsequently  removed  by  swabbing  with  alcohol.  If  the  original  opening 
through  the  bone  does  not  provide  sufficiently  free  access  to  the  disease  or  a 
proper  amount  of  drainage,  enlarge  the  opening  with  the  gouge. 


OSTEOMYELITIS.  813 

Step  4. — Provide  for  drainage  by  rreans  of  a  rubber  tube  or,  better,  by  a 
loose  pack  of  iodoform  gauze.  Partly  close  the  external  wound  with  sutures. 
Apply  abundant  dressings  and  a  splint.  During  the  operation  as  detailed, 
no  focus  of  disease  may  be  recognized.  This  does  not  by  any  means  signify 
a  mistaken  diagnosis,  it  means  either  that  operation  has  anticipated  the  gross 
appearances  of  disease  or  that  the  surgeon  has  failed  to  strike  the  focus.  It 
is  proper  to  make  a  further  search  for  the  focus  of  disease  by  drilling  subsidiary 
holes  in  various  directions.  If  after  this  no  focus  is  found,  provide  for  drainage 
as  described.  If  the  operation  has  been  performed  before  gross  pathologic 
changes  have  arisen,  the  drainage  provided  may  well  lead  to  resolution  taking 
place.  If  gross  pathologic  changes  are  present  but  have  not  been  discovered, 
it  is  almost  certain  that  the  pus  will  soon  evacuate  itself  into  the  bone  wound 
made  by  the  surgeon. 

Subperiosteal  Abscess. — If  in  Step  i  pus  is  found  situated  under  the 
periosteum  or  if  instead  of  pus  inflammatory  exudate  is  there  present,  are  we 


Fig.  949. 


to  content  ourselves  with  the  evacuation  of  this  focus  and  call  the  disease 
"periostitis"?  This  must  be  rarely  necessary.  Exceptionally  the  patient 
may  be  so  weakened  from  absorption  of  toxins  that  the  surgeon,  after  evacuat- 
ing the  subperiosteal  abscess  and  finding,  on  superficial  examination,  no 
evident  communication  with  the  inside  of  the  bone,  concludes  that  an  imperfect 
operation  will  be  life-saving  while  a  more  radical  operation  may  be  left  until 
the  drainage  has  permitted  recovery  from  the  more  urgent  symptoms.  Very 
many  cures  have  been  obtained  by  this  imperfect  operation,  but  it  is  so  uncer- 
tain and  the  disease  is  so  grave  that  nothing  short  of  radical  intervention  is 
justifiable  in  the  large  majority  of  cases.  The  operation  ought  to  be  carried 
out  on  the  following  lines: 


8l4  OSTEOMYELITIS. 

Expose  and  divide  the  periosteum.  Evacuate  the  pus.  Scrape  away 
all  diseased  tissue.  Swab  with  Harrington's  solution  or  with  liquid  carbolic 
acid  followed  by  swabbing  with  alcohol.  Examine  the  exposed  bone  for  any 
fistulae  or  crevices  through  which  pus  escapes.  If  the  subperiosteal  pus  is  on 
the  popliteal  surface  of  the  bone,  retract  the  soft  parts  and  examine  the  bone 
carefully  with  a  probe.  If  a  fistula  leads  into  the  bone  enlarge  it,  and  follow 
it  into  the  focus  of  disease.  WTien  the  fistula  opens  on  the  popliteal  surface 
of  the  bone,  it  is  often  impossible  to  follow  it,  in  which  case  the  bone  must  be 
penetrated  from  the  side  (Fig.  949).  If,  after  thorough  cleansing  of  the  sub- 
periosteal abscess  and  painstaking  examination,  no  disease  of  the  surface 
of  the  bone  is  discovered,  penetrate  into  the  bone  as  in  Step  2  (p.  8ii)  and 
proceed  as  there  advised. 

As  J.  C.  Warren  writes,  "No  operation  which  does  not  include  an  opening 
into  the  bone  should  be  regarded  as  a  completed  one." 

When  pus  has  broken  through  the  periosteum  and  abscess  of  the  more 
superficial  structures  is  evident,  the  operative  treatment  must  be  carried  out 
on  the  lines  already  described. 

(B)  Abscess  of  Bone.  Late  Operation. — The  patient  has  survived  the 
early  and  most  acute  phases  of  the  osteomyelitis.  No  gross  masses  of  bone 
have  died  or  if  so,  they  have  been  destroyed.  The  neighboring  bone  has 
reacted  against  the  inflammation  and  has  surrounded  the  focus  with  a  rampart 
of  thickened  and  sclerosed  bone  through  which  fistulae  lead  to  the  skin.  Drain- 
age is  imperfect,  but  the  main  impediment  to  recovery  consists  in  the  sclerosed 
bone  which  will  neither  provide  healthy  granulation  tissue  to  obliterate  the 
abscess  cavity,  nor  permit  its  walls  to  collapse.  The  objects  of  operation  are 
(a)  to  cleanse  the  abscess  cavity  thoroughly;  (b)  to  obliterate  it. 

These  objects  may  be  attained  in  more  than  one  way. 

Method  A. — Step  i. — After  applying  the  elastic  constrictor,  expose  the 
bone  freely  by  a  suitable  incision  as  in  an  acute  case. 

Step  2. — With  a  gouge  and  mallet  expose  the  abscess  cavity  freely  and 
clean  it  thoroughly.  Dissect  away  the  diseased  lining  of  all  fistulas.  Thoroughly 
disinfect  as  in  acute  cases.  After  the  thorough  cleansing,  temporarily  pack 
the  wound  with  gauze;  clean  the  skin  around  the  wound;  replace  all  soiled 
towels  by  clean  ones;  discard  all  instruments  which  have  been  in  contact  with 
the  wound  up  to  this  time;  let  the  surgeon  and  assistant  clean  their  hands  or 
change  their  gloves.  It  is  important  to  act  as  if  the  completion  of  Step  2 
was  the  completion  of  the  operation,  the  further  steps  being  considered  as  a 
new  operation  performed  on  a  clean  patient,  with  all  the  appliances  fresh  and 
clean. 

Step  3. — Remove  the  pack  from  the  wound.  With  gouge  and  mallet  cut 
away  the  sclerosed  bone  from  around  the  site  of  the  abscess,  until  healthy 
bone  is  reached.  The  object  of  this  is  to  leave  the  cavity  lined  with  bone 
from  which  it  is  reasonable  to  suppose  that  healthy  granulation  tissue  will 
grow  and  obliterate  it.     The  removal  of  the  sclerosed  bone  is  entirely  analogous 


BONE    PLUGS.  815 

to  the  removal  of  scar  tissue  from  around  a  vesico-vaginal  fistula  before  closing 
it  with   sutures. 

Step  4. — Loosely  pack  the  cavity  with  iodoform  gauze.  Apply  liberal 
dressings.  If  necessary,  apply  a  splint.  Put  the  patient  in  bed  with  the 
limb  elevated.     Remove  the  elastic  constrictor. 

The  subsequent  treatment  consists  in  keeping  the  wound  clean  and  encourag- 
ing the  formation  of  granulation  tissue.  Remember  that  the  open  air,  good 
food,  good  company  and  good  amusements  are  the  best  tonics  and  that  the 
patient  requires  such. 

Method  B.— Use  of  Bone  Plugs.  Mosetig-Moorhofs  Method  ("Zent. 
fiir  Chir.,"  April   18,   1903). 

Steps  I,  2,  3,  as  in  Method  A.  To  remove  any  blood-clots  adhering  closely 
to  the  bone,  Mosetig  uses  peroxide  of  hydrogen.  After  every  particle  of  bone 
even  suspected  of  disease  has  been  removed  and  with  it  the  sclerosed  bone, 
the  cavity  must  be  thoroughly  dried.  For  this  purpose  a  douche  of  hot  air  is 
most  valuable.  The  simplest  hot-air  douche  is  shown  in  figure  950.  The 
cavity  is  now  ready  to  be  filled. 


Fig.  950. 

Step  4. — The  following  prescription  has  been  prepared  before-hand: 
Iodoform,  60  parts;  spermaceti,  40  parts;  oil  of  sesame,  40  parts.  Heat 
slowly  to  100°  C.  When  the  mass  cools  it  forms  a  soft  solid  at  the  body  tempera- 
ture. Immediately  before  use  heat  the  iodoform  mixture  in  a  water-bath 
to  60°  C.  to  render  it  fluid.  Pour  it  into  the  bone  cavity  very  slowly  so  as  to 
avoid  the  formation  of  air-bubbles.  Fill  the  bone  cavity  completely.  As 
soon  as  the  mass  solidifies,  replace  and  suture  the  periosteum  and  soft  parts 
in  position.  If  one  or  more  fistulae  are  present,  these  act  as  drains;  if  such 
are  absent,  spaces  between  the  sutures,  or  a  strip  of  rubber  tissue  will  serve 
the  purpose.  Before  suturing,  ligate  any  divided  vessels  which  may  be  visible. 
Apply  dressings  and  if  necessary  a  splint.* 

Put  the  patient  in  bed  with  the  limb  elevated  and  only  then  remove  the 
elastic  constrictor.  The  iodoform  wax  plug  fills  the  cavity  until  such  time  as 
granulation  tissue  and  ultimately  bone  penetrates  and  replaces  it.  Elsberg, 
using  Mosetig's  plug,  has  modified  the  method  of  application  as  follows: 

*  A  splint  is  required  if  one  wishes  to  immobilize  a  neighboring  joint  or  if,  as  is  sometimes 
the  case,  a  mere  shell  of  bone  is  left  full  of  the  iodoform  wax  plug. 


8l6  OSTEOMYELITIS. 

Remove  the  elastic  constrictor  before  pouring  in  the  plug.  Gain  the  necessary 
dryness  by  applying  adrenalin  gauze.  Permit  the  iodoform  wax  to  partially 
harden  outside  the  body  and  then  with  the  fingers  press  bits  of  it  into  the  walls 
of  the  cavity  until  the  whole  space  is  filled  in  the  manner  a  dentist  fills  a  cavity 
in  a  tooth. 

To  the  writer  Elsberg's  modifications  do  not  seem  to  be  improvements. 
Method  C. — Is  the  same  as  Method  A  except  that  in  Step  3  so  much  bone 
is  removed  that  the  soft  parts  can  readily  come  into  contact  with  the  whole  of 
the  wall  of  the  cavity  left.  The  particulars  of  this  method  will  be  more  fully 
described  under  Necrotomy.  Various  plastic  operations  devised  to  fill  bone 
cavities   will  be  found  described  elsewhere. 

(C)  Osteomyelitis  accompanied  by  death  of  bone.  Methods  of  operating. 
Seiiuestrotomy.  Necrotomy. — The  indications  for  operation  vary  with 
the  acuteness  of  the  disease  and  with  its  extent.  When  the  disease  does  not 
affect  the  whole  thickness  of  the  bone  and  the  sequestrum  is  of  but  moderate 
size,  no  matter  whether  the  disease  be  acute  or  chronic,  no  surgeon  would 
hesitate  to  do  a  radical  operation  and  do  it  promptly.  When  the  disease 
is  very  acute  immediate  operation  is  imperative  to  prevent  death  from  sepsis, 
but  if  the  whole  thickness  or  length  of  the  bone  is  necrosed  differences  of  opinion 
are  permissible  as  to  the  extent  of  the  operation.  If  under  the  above  circum- 
stances the  dead  bone  is  found  separated  from  the  living  bone,  in  case  the 
whole  bone  is  affected,  it  is  separated  from  the  surrounding  tissues,  no  good 
but  rather  much  evil  may  be  expected  from  its  retention,  hence  it  must  be 
removed.  If,  however,  the  dead  bone  is  not  entirely  free  it  is  often  the  best 
practice  to  drain  away  all  the  products  of  inflammation  but  leave  the  sequestrum 
in  situ  to  act  as  a  splint  until  new  bone  bas  been  formed  sufficient  in  quantity 
to  preserve  continuity.  Should  the  irritation  from  the  presence  of  the  dead 
bone  keep  up  so  much  inflammation  as  to  endanger  life  or  should  its  presence 
interfere  with  proper  drainage,  then  it  must  be  removed.  In  almost  all  sub- 
acute and  chronic  cases  of  extensive  necrosis,  it  is  possible  and  wise  to  delay 
removal  of  the  sequestrum  until  sufficient  new  bone  has  been  formed  to  main- 
tain continuity.  During  this  period  of  waiting  efiflcient  drainage  must  of  course 
be  provided. 

In  the  succeeding  paragraphs  operations  on  the  tibia  will  be  generally 
taken  as  typical. 

(a)  The  extent  of  necrosis  is  not  great.  Operate  exactly  as  for  acute  or 
chronic  abscess  of  the  bone,  removing  sequestra — if  loose,  with  forceps;  if 
fixed,  with  the  chisel. 

(b)  The  necrosis  is  extensive  as  regards  length,  but  enough  healthy  bone 
remains  or  enough  involucrum  has  been  formed  to  insure  the  continuity  of 
the  bone.  The  old  method  of  treating  this  class  of  cases  was  to  enlarge  one 
of  the  fistulse  leading  through  the  involucrum  and  through  this  to  extract  the 
sequestrum  in  one  or  more  fragments,  provided  it  was  loose;  if  the  sequestrum 
was  found  still  attached  to  the  living  bone,  operation  was  given  up  until  sepa- 


SEQUESTROTOMY  OR  NECROTOMY. 


817 


If,  as  is  the 


Fig.  95 1 . — The  bone  is  divided  at  A  and 
B  and  the  shaded  area  removed. 


ration  was  complete.     Such  a  procedure  gives  no  opportunity  to  clean  the  dirty 
cavity  which  contained  the  bone  and  has  been  entirely  discarded. 

Typical  Seqestrotomy. — Step  i. — Make  a  longitudinal  incision  down 
to  the  bone  throughout  the  whole  length  of  the  disease.  This  incision  may 
pass  through  the  mouths  of  one  or  more  fistulae  or  may  be  independent  of 
such.  Denude  the  bone  of  periosteum  for  about  1/2  inch  on  each  side  of  the 
longitudinal  incision.     Retract  the  soft  parts. 

Step  2. — If  the  sequestrum  is  entirely  superficial  remove  it. 
rule,  the  sequestrum  lies  inside  a  coffin 
(involucrum)  of  new  bone,  perforated  by 
fistulcT,  proceed  as  follows:  With  chisel 
and  mallet  remove  enough  of  the  new  bone 
to  give  access  to  the  whole  of  the  sequestrum 
and  to  every  part  of  the  cavity  in  which  it 
lies.  Remove  the  sequestrum,  if  necessary 
cutting  it  from  the  living  bone  with  the 
chisel  or  other  appropriate  instrument. 

In  removing  a  portion  of  the  involucrum 
to  expose  the  dead  bone,  if  possible,  do  so  in 
such  a  manner  that  the  whole  of  one  wall 
of  the  cavity  is  removed,  the  whole  of  the 
other  side  or  wall  being  retained,  thus  after 

the  sequestrum  is  taken  away  and  the  cavity  cleansed  the  overlying  soft  parts 
may  naturally  fall  into  and  obliterate  the  cavity  (Fig.  951). 

After  removing  the  dead  and  infected  portions  of  the  bone  there  may  be  a  mere 
splint  of  sound  bone  (cortical  bone)  left  maintaining  continuity.  This  is  quite 
sufficient  as  it  wall  thicken  and  grow^  rapidly.  As  the  extensive  removal  of  bone 
has  completely  done  away  with  the  bone  cavity,  the  soft  parts  can  be  brought 
together  and  healing  by  first  intention  sought.  Several  different  methods  of 
attacking  the  bone  with  a  view  to  obliterating  the  cavity  will  be  described  later. 

While  working  on  the  bone  be  careful  to  avoid  fracturing  that  portion  of 
the  involucrum  which  is  to  be  retained  and  on  which  the  continuity  of  structure 
depends. 

Step  3. — With  the  curette,  aided  if  necessary  by  the  gouge,  remove  all 
diseased  granulation  tissue  and  bone  from  the  inside  of  the  involucrum  and 
from  any  existing  fistulae.  Swab  the  cavity  vdth  Harrington's  solution  or  with 
liquid  carbolic  acid  (95  per  cent.)  subsequently  swabbing  with  alcohol.  Ochs- 
ner  follows  this  by  applying  tincture  of  iodine.  If  there  is  any  doubt  as  to  the 
complete  removal  of  all  infected  tissue,  pack  the  cavity  with  iodoform  gauze 
and  if  the  wound  is  found  aseptic,  after  a  few  days  close  it  with  sutures.  If 
it  is  believed  that  all  disease  has  been  removed  the  wound  may  be  closed 
at  once,  any  non-obliterated  cavities  being  drained,  or  the  cavity  may  be  filled 
with  Mosetig-Moorhof  iodoform  and  wax  plug.  After  dressings  are  applied 
fix  the  limb  in  a  splint.     Regeneration  of  the  bone  is  usually  rapid. 


8l8  OSTEOMYELITIS. 

Methods   of   Obliterating  the  Bone   Cavity  after  Sequestrotomy. — 

It  is  assumed  that  the  sequestrum  and  all  diseased  tissue  have  been  completely 
removed,  that  the  cavity  has  been  disinfected  and  packed  with  gauze,  that  the 
skin  around  the  wound  has  been  prepared  as  if  for  a  new  aseptic  operation, 
that  the  surgeon  and  assistants  have  prepared  themselves  and  the  instruments 
as  if  for  a  fresh  operation. 

I.  Schede's  Aseptic  Blood-clot.— Remove  the  pack  of  gauze  from  the 
bone  cavity.  Unite  the  divided  periosteum  and  soft  parts  with  fine  buried 
sutures  in  layers.  Close  the  skin  wound.  Provide  drainage  by  a  few  strands 
of  catgut,  a  chicken-bone  tube  or  a  strip  of  rubber  tissue.  Apply  abundant 
dressings.  Immobilize  the  limb  in  an  almost  vertical  position.  Remove 
the  elastic  constrictor.  Enough  bleeding  takes  place  to  fill  the  cavity  with  blood. 
Any  excess  of  blood  is  carried  into  the  dressings.  The  elevated  posture  pre- 
vents all  dangerous  or  inconvenient  hemorrhage  and  may  be  safely  discon- 
tinued after  twelve  to  twenty-four  hours.  If  everything  progresses  favorably  a 
large  cavity  may  heal  under  one  dressing  in  about  six  weeks.  Keep  a  very 
sharp  watch  for  signs  or  symptoms  of  decomposition  in  the  wound  as  this  is 
liable  to  occur  and  necessitates  immediate  evacuation  and  drainage. 

II.  Senn's    Decalcified    Bone    Chips.    Preparation    of    the    Chips. 

"  Select  the  compact  layer  of  the  fresh  tibia  or  femur  of  the  ox,  remove  all  periosteum  and 
medullary  tissue,  divide  into  longitudinal  strips  about  i/8  of  an  inch  wide  and  immerse  in  a 
relatively  large  quantity  of  lo  to  15  per  cent,  watery  solution  of  hydrochloric  acid  which  must 
be  renewed  daily,  for  from  one  to  two  weeks;  then  wash  thoroughly  in  water  or  a  weak  solution 
of  caustic  potash,  cut  into  small  chips,  soak  for  forty-eight  hours  in  1:1000  mercuric  bichloride 
solution,  remove  and  store  in  a  saturated  solution  of  iodoform  in  ether.  When  about  to  be 
used,  wrap  in  aseptic  gauze,  dissolve  out  the  excess  of  ether  and  iodoform  with  alcohol  and  put 
in  1:2000  mercuric  bichloride  solution  until  required,  when  careful  drying  with  iodoform 
gauze  should  precede  their  implantation."     (Senn). 

Remove  the  gauze  pack  from  the  bone  cavity.  Fill  the  cavity  completely 
with  the  decalcified  bone  chips.  Treat  exactly  as  in  Schede's  method.  The 
interstices  between  the  chips  become  filled  with  blood.  The  bone  chips,  it 
is  claimed,  strengthen  the  frame-work  of  blood-clot  into  which  the  healthy 
granulation  tissue  penetrates,  while  being  impregnated  with  iodoform  they 
keep  that  drug  disseminated  throughout  the  blood  clot  where  it  inhibits  bacte- 
rial activity. 

Instead  of  decalcified  chips  such  foreign  material  as  plaster  of  Paris,  amal- 
gam and  chips  of  fresh  bone  have  been  used  with  occasional  success.  Neuber 
believes  the  whole  value  of  Senn's  bone  chips  lies  in  the  fact  that  they  keep 
iodoform  diffused  through  the  blood-clot,  but  that  the  bone  chips  themselves 
are  objectionable  as  they  are  too  slowly  absorbed.  Iodoform  glycerine  is 
valueless  as  a  substitute  because  the  iodoform  in  it  is  quickly  precipitated. 
Neuber's  method  is  as  follows: 

III.  Neuber's  Iodoform  Starch. — ^Preparation  of  the  starch.  Mix  10 
grams  of  wheat  starch  with  the  smallest  possible  amount  of  water  in  an  open 
glass  vessel,  pour  into  this,  constantly  stirring  the  mixture,  200  grams  of  boiling 
2  per  cent,  watery  carbolic  solution.     After  partial  cooling,  stir  in  10  grams 


BONE    PLUGS.  819 

of  powdered  iodoform.  Pour  into  a  sterile  glass  flask.  This  mixture  may  be 
kept  for  weeks  in  a  dark  room.  It  is  used  in  the  same  fashion  as  Mosetig- 
Moorhof's  iodoform  wax.  Neuber  considers  this  method  suitable:  (a)  after 
superficial  sequestrotomies  and  the  removal  of  superficial  tuberculous  foci;  (b) 
after  sequestrotomies  when  the  bone  cavity  is  deep  and  large  but  its  edges 
are  imiform  and  sloping  (not  overhanging). 

IV.  Mosetig-Moorhof's  iodoform  wax  plug  has  already  been  described. 

V.  Emil  Beck's  bismuth  paste  ("Journal  A.  M.  A.,"  March  14,  1908) 
may  be  used  in  a  manner  similar  to  Neuber's  starch.  The  formula  of  the 
paste  is  as  follows: 

Bismuth    subnitrate 30.0  grams.     (Carbonate?) 

WTiite    wax      5.0  grams. 

Soft    paraffin 5.0  grams. 

Vaseline    60.0  grams. 

Mix  while  boiling.  Do  not  spill  any  water  into  the  paste  while  boiling. 
If  a  syringe  is  used  to  insert  the  paste  it  should  be  sterilized  by  the  dry  process 
and  the  plunger  dipped  in  sterile  vaseline  instead  of  water.  Soft  paraflan 
differs  from  hard  paraffin  in  being  absorbable.  Occasionally  Beck  adds 
I  per  cent,   of  formalin  to  the  paste. 


Fig.  952. 


Fig.  953. 


As  a  number  of  cases  of  nitrite  poisoning,  some  fatal,  have  been  observed 
after  the  use  of  subnitrate  of  bismuth,  it  is  recommended  that  the  carbonate 
of  bismuth  be  used  in  place  of  the   subnitrate. 

VI.  The  cavity  left  after  removal  of  the  sequestrum  has  walls  which  pre- 
vent obliteration  by  the  falling  in  of  the  overlying  soft  parts.  With  the  chisel 
cut  through  the  bone  at  the  base  of  one  of  the  walls  for  the  whole  length  of  the 
cavity,  but  carefully  avoid  cutting  the  periosteum.  Remove  a  wedge-shaped 
strip  of  bone  A  B  C  D  along  this  line  of  section  to  permit  the  mobilized  bone 
to  fall  in  and  obliterate  the  cavity  (Figs.  952  and  953). 

VII.  Osteoplastic  method  of  M.  W.  af  Schulten  ("Archiv.  fiir  klin.  Chir.," 
lii,  145).  Of  this  method  there  are  several  varieties,  in  all  of  these  the  anterior 
wall  of  the  bone  cavity  (of  the  tibia)  is  removed,  sequestra,  etc.,  extracted,  the 
cavity  disinfected  and  packed  with  gauze  for  about  three  weeks  or  until  it  is 


820 


OSTEOMYELITIS. 


covered  with  healthy  granulation  tissue.  After  being  packed  with  gauze 
the  wound  should  be  jDartly  closed  with  sutures  to  prevent  too  much  retraction 
of  the  soft  parts. 

Variety  a  of  Method  (the  whole  shaft  of  the  tibia  is  affected). — Step  i. — 
Completely  remove  the  two  lateral  walls  of  the  bone  cavity  in  its  middle  third 
(Fig.  954),  leaving  the  posterior  wall   to  maintain  continuity. 

Step  2. — At  the  upper  and  lower  ends  of  the  primary  incision  (made  in  the 
previous  operation  and  now  reopened)  make  transverse  incisions  down  to  the 
bone  (Fig.  954,  i,  i).  Through  these  cuts  divide  the  lateral  walls  of  the  cavity 
transverselv. 


Fig.   955. 


054- 


Step  3. — Introduce  a  chisel  into  the  bone  cavity  through  the  anterior  open- 
ing made  at  the  first  operation  and  cut  through  the  junction  of  the  lateral 
walls  (A,  B,  Fig.  955)  with  the  posterior  wall  (C,  Fig.  955)  of  the  cavity.  Be 
careful  to  leave  the  periosteum  intact. 

Step  4. — From  the  edge  of  the  posterior  wall  (C)  of  the  cavity  or  the  bases 
of  the  lateral  walls  shave  away  enough  bone  to  permit  the  lateral  walls  to 
slide  together  (Fig.  955). 

Step  5. — Approximate  the  lateral  walls  (Figs.  955-956  A,  B)  and  fix  them 
by  periosteal  or  bone  sutures  as  may  be  convenient.  Close  the  wound  in  the 
soft  parts.     Dress  and  apply  a  splint. 

N.  B. — The  object  in  treating  the  upper  and  lower  thirds  of  the  bone 
diiferently  from  the  middle  third  is  that  the  portions  of  the  cavity  situated 
at  the  ends  of  the  bone  are  more  difficult  to  obliterate  by  the  falling  in  of  the 
soft  parts  than  is  that  part  in  the  middle  of  the  shaft. 


OBLITERATION    OF    CAVITIES. 


821 


Variety  b  of  Method. — Divide  the  lateral  walls  of  the  cavity  transversely 
at  both  its  extremities  and  also  at  its  middle  (Fig.  957).  Mobihze  and  approxi- 
mate the  lateral  walls  as  in  variety  a.  Here  the  whole  cavity  is  obliterated 
in  the  method  used  in  the  previous  operation  for  the  upper  and  lower  ends. 
Mobilization  of  each  lateral  wall  in  two  segments  is  more  easily  accomplished 
than  in  one,  hence  the  transverse  incision  in  the  middle. 

VIII.  Neuber's  Method  of  Invagination. — Sequestrotomy  has  been  per- 
formed, the  wound  has  been  disinfected,  and  all  sclerosed  connective  tissue  has 
been  dissected  away.  With  the  chisel  remove  most  of  the  lateral  walls  of  the 
bone  cavity,  but  preserve  the  periosteum  unless  it  is  infected. 
Invaginate  the  overlying  soft  parts  and  fix  them  in  position 
by  suture,  pegs,  or  strapping.  Figures  958,  959,  960  explain 
the  method  more  clearly  than  words. 

IX.  M.  W.  af  Schulten's  method  for  obliteration  of 
cavities  in  lower  end  of  femur. 

Cavities  at  the  lower  end  of  the  femur  are  not  so  amena- 
ble to  the  ordinary  means  of  obliteration  as  are  those  in  the 
tibia  or  the  shaft  of  the  femur.  Af  Schulten  ("Archiv.  fur 
klin.  Chir.,"  liv,  328)  advises  filling  the  cavity  with  a  flap 
of  muscle  and  periosteum.  The  operation  is  done  in  two 
stages. 

Stage  I. — This  is  the  same  as  for  old  abscess  plus  seques- 
trotomy and  need  not  be  described  again. 

Stage  2. — This  is  undertaken  two  to  three  weeks  after 
Stage  I.     Apply  an   elastic   constrictor. 

Step  I. — With  the  sharp  spoon  remove  all  the  granulation 
tissue  from  the  wound  and  the  bone  cavity.     Disinfect  the  cavity  as  thoroughly 
as  possible.     Pack  the  cavity  temporarily. 

Step  2. — Supplement  the  primary  longitudinal  incision  by  a  transverse 
one  involving  the  skin  alone.  Reflect  the  skin  as  in  Fig.  961,  exposing  the 
deep  fascia. 

Step  3. — Make  the  flap  ABC  (Figs.  961  and  962),  consisting  of  deep  fascia, 
muscle,  and  periosteum  and  having  its  pedicle  above.  The  flap  must  be 
long  enough  and  so  located  that  it  will  easily  fall  into  the  bone  cavity  after 
being  mobilzed  (Fig.  963).  (In  mobilizing  the  flap  it  may  perhaps  be  well 
to  use  a  chisel  instead  of  an  elevator  and  so  leave  a  thin  shell  of  bone  or  some 
fragments  of  bone  attached  to  the  periosteum.)  If  the  shape  of  the  upper  end 
of  the  bone  cavity  interferes  with  the  pedicle  of  the  flap  when  it  is  implanted 
into  the  cavity,  trim  the  bone  with  the  chisel  until  the  fault  is  eliminated. 

Step  4. — Remove  the  elastic  constrictor.  Attend  to  hemostasis.  Remove 
the  temporary  pack  from  the  bone  cavity.  Fill  the  cavity  with  the  mobilized 
flap  (Fig.  963).  Fix  the  flap  with  a  few  catgut  sutures.  Close  the  skin 
(Fig.  964)  wound  with  or  without  drainage.  Apply  dressings  and  a  splint. 
Keep  the  limb  elevated  for  twenty-four  hours. 


822 


OSTEOMYELITIS. 


Af  Schulten  considers  that  any  pressure  exerted  upon  the  wound  may 
interfere  with  the  vitality  of  the  transplanted  flap,  hence  he  covers  the  area 
of  the  wound  with  a  wire  cage  over  which  he  lays  a  few  layers  of  gauze.  By 
this  means  no  dressings  touch  the  wound  area  which  is  protected  completely 
from  all  irritation  by  the  gauze  covering  the  wire  cage.     The  author  uses  a 


Fig.  958. 

similar  method  for  the  protection  of  areas  covered  with  Thiersch's  skin  graft 
and  finds  it  excellent.  He  surrounds  the  area  with  a  cushion  of  sterile  gauze 
or  cotton,  like  a  bird's  nest  or  ring  cushion  and  covers  the  hole  in  the  centre 
of  the  cushion  with  a  few  layers  of  gauze.  This  permits  evaporation  of  dis- 
charges and  at  the  same  time  keeps  away  irritation.     When  the  bone  cavity 


Fig.  959. 


Fig.  960. 


is  very  deep,  two  muscle  and  periosteal  flaps  may  be  used  one  above  the  other 
(Figs.  965,  966). 

When  the  bone  cavity  is  very  long,  two  flaps  may  be  used  as  shown  in 
figures  967,  968.  Similar  procedures  may  be  applied  to  the  obliteration  of 
cavities  in  other  locations. 


NECROTOMY. 


823 


(c)  The  whole  or  almost  the  whole  shaft  of  the  bone  is  necrosed,  the 
periosteum  is  almost  entirely  separated  from  the  bone  and  between  these 
two  structures  there  is  much  pus. 


Fig.  961. —  {Af  Schiilten.) 


Fig.  962. —  {Af  SchuUen.) 


-H- 


Fig.  g6T,.~{Af  Schultm.) 


Fig.  964. — {A f  SchuUen.) 


As  already  mentioned,  if  efficient  drainage  can  be  maintained,  it  is  wise 
to  retain  the  sequestrum  as  a  splint,  especially  as  many  cases  are  known  in 
which  partial  regeneration  of  the  apparently  dead  bone  has  taken  place.     If, 


824 


OSTEOMYELITIS. 


however,  in  spite  of  free  drainage  symptoms  of  intoxication  persist  the  dead 
bone  must  be  removed.  If  a  disk  of  healthy  bone  is  left  between  the  shaft  and 
epiphysis  no  deformity  from  shortening  need  be  anticipated  (G.  B.  Johnston). 


Fig.  g6s.—(AfSc/mlten.) 


Fig.  g66.—  ( AfSchulten.) 


^1 


I  ) 


iilHi 


ii 


Fig.  967. — {AfSchullen.) 


Fig.  g68.— {A/ Schidlen.) 


When  the  tibia,  for  example,  is  removed  its  companion  bone,  the  fibula,  takes 
on  compensatory  hypertrophy.  G.  Ben  Johnston  ("Transactions  Am. 
Surg.   Assoc,"   xxii)    thus   describes   the   operation: 


OSTEOPLASTY. 


825 


"  (a)  Free  incision  and  complete  removal  of  all  (iiseased  bone. 

"(b)  Spare  all  periosteum  possible. 

"(c)  Avoid  curette,  or  use  cautiously. 

"(d)  Purify  the  wound  by  the  strictest  antiseptic  methods. 

"After-treatment.— (a)  Maintain   aseptic   conditions. 

"(b)  Avoid   too   frequent   and   rough   dressings. 

"(c)  Treat  as  a  fracture  by  immobilization  in  a  fracture  box. 

"(d)  Carefully  shape  the  parts,  as  bone  tissue  develops,  by  bandages  or 
adhesive  straps. 

"(e)  Protect  the  young  bone  by  means  of  plaster  of  Paris. 

*'(f)  Abstain  from  the  use  of  the  limb  until  the  new  bone  is  capable  of 
sustaining  the  weight  of  the  body. 

"(g)  Look  after  the  general  health." 


Fig.  969. — {^.  Eiselsberg.) 


Fig.  970. — -(v.  Eiselsberg.) 


X.  Von  Eiselsberg's  method.  Treatment  of  large  defects  in  tibia.  Von 
Eiselsberg  ("Archiv.  fiir  klin.  Chir.,"  Iv,  435)  extended  the  Konig-Miiller 
method  of  closing  cranial  defects  to  the  treatment  of  large  defects  in  the  tibia. 
While  the  method  was  devised  to  repair  the  damage  done  by  the  removal 
of  a  sarcoma,  it  may  be  employed  to  rectify  defects  from  other  causes,  e.g., 
from  total  necrosis  of  a  long  segment  of  the  bone. 

Step  I. — Apply  an  elastic  constrictor.  Clean  and  vivify  the  defect  to  be 
filled.  If  very  little  of  the  lower  end  of  the  tibia  remains  it  may  be  removed 
and  a  portion  of  the  astragalus  vivified  for  the  reception  of  the  flap. 

Step  2. — Divide  the  skin  so  as  to  make  the  flap  ABC,  figure  969.  With 
a  chisel  make  an  incision  through  the  whole  thickness  of  the  cortical  bone 
along  the  dotted  line  in  figure  969.  Do  not  in  any  way  separate  the  soft  parts 
from  the  bone  within  the  encircling  bone  incision.     With  the  chisel  separate 


826  OSTEOMYELITIS. 

the  divided  cortical  bone,  in  one  piece  with  the  periosteum  and  skin,  from  the 
medullary  bone.  This  gives  us  a  flap  of  skin,  periosteum,  and  cortical  bone 
provided  with  a  pedicle  at  A. 

Step  3. — Twist  the  flap  into  position  to  fill  the  tibial  defect  (Fig.  970). 
Suture  it  in  position.  Do  not  apply  too  much  torsion  to  the  pedicle,  and 
when  applying  dressings  do  not  let  them  exert  much  pressure  either  on  the 
pedicle  or  on  the  flap. 

Step  4. — Close  the  wound  left  on  the  upper  part  of  the  leg  by  sliding  the 
skin  over  the  osseous  wound.  Complete  closure  will  often  be  impossible, 
but  the  resultant  space  may  be  subsequently  covered  by  Thiersch's  skin  grafts. 

Step  5. — Apply  dressings  and  a  splint.  Place  the  limb  in  a  vertical  position. 
Remove  the  elastic  constrictor. 


CHAPTER  LXXII. 
TUMORS  OF  BONE. 

1.  Benign. — Removal  of  the  neoplasm  itself  is  usually  all  that  is  necessary 
for  a  cure.  If  the  tumor  involves  so  much  bone  that,  after  its  removal,  restora- 
tion of  the  continuity  of  the  limb  becomes  impossible  or  inadvisable,  then 
amputation  may  be  necessar}-. 

Simple  cysts  of  the  long  bones  have  no  connective  tissue  capsule,  but 
islands  of  cartilage  may  exist  in  the  bony  capsule.  They  should  merely  be 
curetted  and  drained.  Ordinary  dentigerous  cysts  merely  require  evacuation 
of  their  contents,  removal  of  their  membranous  lining  and  excision  of  just 
so  much  of  their  bony  w^all  as  will  correct  deformity.  Adamantine  epithe- 
liomata  (Bloodgood)  differ  from  dentigerous  cysts  in  containing  white  granu- 
lar tissue.  Such  a  tumor  must  be  excised  with  its  bony  wall,  but  it  is  permis- 
sible to  keep  close  to  the  tumor.  This  tumor  is  included  among  the  benign 
neoplasms  merely  because  it  is  indistinguishable  clinically  from  a  dentigerous 
cyst  and  if  excised  as  above  it  does  not  tend  to  recur.  Osteomata  should  be 
removed  thoroughly  along  with  considerable  of  their  bony  basis.  The  same 
is  true  regarding  enchondromata. 

IL  Tumors  of  a  Low  Grade  of  Malignancy. — Many  of  the  tumors 
referred  to  can  scarcely  be  recognized  before  being  exposed  or  incised. 

Giant-cell  Sarcoma.  Myelogenous  Sarcoma.  Myeloid  Sarcoma. — 
When  cut  into,  the  tumor  presents  a  peculiar  brownish-red  color  like 
liver  or  spleen.  It  is  very  vascular,  hemorrhage  into  it  is  common,  it  is  friable 
and  can  be  broken  up  into  irregular  masses.  The  tumor  usually  grows  in 
the  medullary  cavity  of  the  long  bones  and  is  surrounded  by  a  shell  of  new- 
formed  bone.  It  is  only  locally  malignant,  in  its  earlier  stages  at  least,  and 
generally  grows  slowly  without  much  pain,  causing  a  gradual  and  uniform 
expansion  of  the  bone.  In  time  the  tumor  extends  beyond  the  bone  and  in- 
vades the  soft  parts  and  must  then  be  considered  distinctly  malignant. 

In  its  early  stages  a  giant-cell  sarcoma  may  be  treated  by  excision  of  the 
tumor  and  the  surrounding  bone.  W.  Kramer  writes  ("Archiv.  fiir  klin. 
Chir.,"  Ixvi):  "It  is  only  during  the  operation  that  the  surgeon  can  come 
to  a  conclusion  as  to  the  propriety  of  conservatism.  In  my  two  cases  I  have 
not  been  afraid  to  ascertain  the  condition  of  the  marrow  by  an  exploratory 
evidement  of  the  remaining  bone  and  have  only  proceeded  to  unite  the  ends 
of  the  bone  when  that  has  been  found  normal."  J.  C.  Bloodgood  ("Journal. 
A.  M.  A.,"  Feb.  i,  1908)   writes  of  giant-cell  sarcoma:     "It  may  be  as  slow 

827 


828  TUMORS    OF    BONE. 

of  growth  as  the  cyst.  The  X-ray  shadow  does  not  distinguish  it  positively 
from  any  other  medullary  tumor  having  a  bone  shell.  This  tumor  has  been 
permanently  cured  by  simple  curetting.  Recurrences  have  followed  curet- 
ting, but  were  permanently  eradicated  by  a  second  operation  of  curetting, 
resection,  or  amputation.  Of  over  one  hundred  cases  of  the  pure  tumor  none 
has  given  metastasis.  It  seems  justifiable  at  the  first  operation,  therefore, 
to  attempt  the  most  conservative  method,  even  with  the  risk  of  a  local  recurrence, 
which,  if  it  does  occur,  apparently  is  not  associated  with  any  danger  of  metastasis. 
One  should  not  attempt  curetting  unless  there  is  a  thick  shell  of  bone,  so  that 
the  curette  or  chisel  removes  a  zone  of  bone  beyond  the  tumor.  When  the 
shell  of  bone  is  thin,  subperiosteal  resection  should  be  performed;  when  the 
periosteum  and  surrounding  muscles  have  become  infiltrated,  total  resection 
is  indicated.  In  one  of  my  recorded  cases  in  which  a  cure  was  effected  and 
in  which  there  was  infiltrated  muscle,  the  microscope  demonstrated  the  giant- 
cell  tumor  within  a  few  millimeters  of  the  plane  of  resection.  For  the  periosteal 
giant-cell  tumor  local  resection  with  chiseling  of  a  zone  of  bone  beneath  is 
sufficient." 

O.  Hildebrandt  believes  the  local  removal  of  myeloid  sarcomata  gives 
uncertain  results  and  is  not  advisable. 

Sir  H.  Morris  removed  the  radius  and  ulna  for  a  myeloid  sarcoma  originat- 
ing in  the  former  and  firmly  attaching  the  ulna  to  it.  After  four  years  there 
was  no  recurrence.  Glutton  operated  on  three  cases  of  endosteal  sarcoma 
of  the  radius.  In  one  of  these  the  sawed  end  of  the  bone  showed  a  small 
nodule  of  tumor  in  the  medullary  canal;  after  this  was  removed  by  scraping 
and  gouging  a  cure  seems  to  have  been  obtained.  In  another  case  where  the 
head,  neck,  and  upper  end  of  the  radius  was  excised,  there  was  no  recurrence 
when  the  patient  died  from  renal  disease  after  eighteen  months. 

Herten  (" Zentralblatt  ftir  Chir.,"  Feb.  5,  1910)  reviews  the  cases  (60  in 
all)  of  sarcoma  of  the  long  bones  operated  upon  in  the  Breslan  clinic  between 
1890  and  1909. 

Amputation  or  exarticulation  was  performed  in  advanced  cases  when  the 
sarcoma  did  not  seem  suited  for  resection.  (Twenty  cases  of  periosteal  sarcoma; 
six  of   myelogenous,    central   and   chondro-sarcomata). 

None  of  the  periosteal  sarcomata  was  permanently  cured  while  there  was 
no  recurrence  in  two  cases  of  myeclgenous  sarcoma;  in  one  of  central  round 
cell  sarcoma  and  in  one  of  unknown  variety.  Of  twenty-nine  resections 
five  were  too  recent  for  consideration;  of  the  remaining  twenty-four,  twelve 
were  periosteal,  twelve  myelogenous,  central  and  chondro-sarcomata.  One 
of  the  periosteal  remained  cured  but  only  after  amputation  because  of  poor 
nutrition  of  the  limb  and  reamputation  because  of  recurrence  one  year  later. 
The  group  of  myelogenous  and  central  sarcomata  nine  were  cured  and  three 
died. 

Among  the  nine  which  remained  well  four  required  amputation  subse- 
quently, but  in  five  the  resection  sufficed. 


SARCOMA.  829 

Among  the  twenty-nine  resections,  recurrence  was  recognizable  eight 
times  and  in  eight  cases  amputation  or  exarticulation  was  necessitated  owing 
to  recurrence  or  to  want  of  consolidation. 

Herten  concludes  that  a  high  amputation  or  exarticulation  is  always  indi- 
cated in  periosteal  sarcoma  of  the  long  bones  while  in  myelogenous,  central 
and  chondrosarcoma  resection  is  proper  in  favorable  cases.  In  one  case 
where  a  central  round  cell  sarcoma  of  the  humerus  was  resected  there  was  no 
recurrence  until  after  the  lapse  of  five  years  when  "suddenly  within  six  weeks 
there  was  a  recurrence  the  size  of  a  head." 

Kiittner  cUsapproves  of  conservative  operations  in  periosteal  sarcomata, 
prefers  amputation  even  in  myelogenous  sarcoma  and  thinks  resection  only 
justifiable   in    very   favorable    cases. 

On  the  whole,  one  may  conclude  that  a  conservative  operation  is  proper 
for  the  thorough  excision  of  giant-cell  tumors  affecting  bones  which  are  of 
prime  importance  for  the  efficiency  and  comfort  of  the  patient.  Examples 
of  such  bones  are  the  femur,  the  humerus,  the  radius  or  ulna,  the  jaws,  etc. 
When  a  toe,  finger,  foot,  or  perhaps  even  when  the  tiba  is  the  site  of  the  disease, 
amputation  may  leave  the  patient  as  capable  or  more  capable  of  pursuing 
work  or  pleasure  and  gives  a  better  assurance  of  real  cure.  The  amputation 
ought,  however,  to  be  conservative  and  not  such  as  is  described  later  in  this 
chapter. 

Pure  myxomata  of  bone  (endosteal  or  periosteal)  are  rare.  Treatment  is 
the  same  as  for  giant-cell  sarcomata. 

III.  Malignant  Tumors. — Sarcomata  (round  or  spindle-cell,  angio-sarcoma) 
are  the  malignant  neoplasms  which  occur  primarily  in  bone.  These  tumors 
(whether  central  or  subperiosteal)  early  pass  beyond  the  limits  of  the  bones 
and  infiltrate  the  muscles  and  tendons  attached  to  them.  The  muscles  act 
as  an  excellent  path  for  the  conduction  of  the  infiltrating  neoplastic  tissue  from 
one  bone  to  another,  e.  g.,  the  deltoid  may  conduct  neoplastic  tissue  from  the 
humerus  to  the  scapula.  This  is  important  from  the  standpoint  of  treatment. 
Metastasis  is  very  common  in  spite  of  treatment.  A  classical  rule  in  the  treat- 
ment of  sarcoma  of  bone  was  to  amputate  at  or  above  the  joint  proximal  to  the 
disease,  i.  e.,  to  remove  the  whole  of  the  bone  affected.  This  treatment  ought 
to  be  effective  if  the  tumor  is  still  confined  within  the  bone;  if,  however,  muscu- 
lar infiltration  has  taken  place  even  if  it  is  not  apparent  to  the  naked  eye,  then 
the  only  hope  of  benefit  lies  in  more  extensive  work.  Theoretically  to  achieve 
the  best  permanent  results  one  should  remove  the  bone  primarily  diseased, 
the  muscles  inserted  into  it  and  the  bones  from  which  these  muscles  arise. 
This  theoretical  aim  is  nearly  attained  in  the  case  of  tumors  of  the  humerus 
by  interscapulo-thoracic  amputation.  The  accompanying  statistics  speak  for 
themselves. 

Berger.  Forty-six  cases.  Primary  mortality,  5  per  cent.  Free  from 
recurrence  after  one  year,  33  per  cent. 

Konitzer.     Primary  mortality,  4  per  cent.     Known  recurrence,  21  per  cent. 


830  TUMORS    OF    BONE. 

Free  from  recurrence  in  less  than  one  year,  34  per  cent.  Free  from  recurrence 
longer  than  one  year,  21  per  cent.     Untraced  24  per  cent. 

The  same  principle  may  be  easily  carried  out  in  sarcomata  of  the  foot  by 
amputating  above  the  knee.  Unfortunately,  in  many  or  most  instances  practi- 
cal considerations  (primary  danger,  unendurable  deformity,  etc.)  prevent  the 
attainment  of  the  ideal.  Under  these  circumstances  one  may  amputate  as 
high  as  possible  and  at  the  same  time  remove  as  thoroughly  as  possible  the 
muscles  inserted  into  the  diseased  bone,  especially  those  most  likely  to  be  in- 
volved. Example:  Periosteal  sarcoma  on  the  outer  side  of  the  head  of  the 
tibia.  Amputation  above  the  knee  is  necessary.  It  is  probable  that  any 
neoplastic  invasion  of  the  tendo  patellae  will  be  slow  to  spread  upwards  beyond 
the  patella;  hence  if  the  disease  is  tolerably  recent  the  quadriceps  extensor  may 
be  considered  reasonably  safe.  The  biceps  is  the  muscle  most  probably  in- 
volved, hence  as  soon  as  the  amputation  is  completed  and  the  main  vessels 
ligated  it  seems  to  the  writer  most  reasonable  to  expose  this  muscle  throughout 
its  whole  length  and  to  excise  it  completely. 

Carcinomata  and  hypernephromata  are  always  secondary  to  disease  else- 
where and  any  operation  performed  on  them  must  be  considered  merely 
palliative,  except  when  the  primary  tumor  has  directly  invaded  the  affected 
bone  and  can  be  removed  with  it. 


CHAPTER  LXXIII. 

CHONDRECTOMY. 

It  is  well  known  that  when  osteomyelitis  affects  an  active  (fertile)  epiphyseal 
cartilage  one  of  two  things  may  happen:  (a)  The  cartilage  may  be  destroyed  and 
as  a  consequence  growth  of  the  bone  cease,  (b)  The  cartilage  may  be  stimu- 
lated and  growth  of  the  bone  become  excessive.  Where  the  diseased  epiphyseal 
cartilage  is  that  of  one  of  the  bones  of  the  forearm  or  leg,  deformity  results 
because  of  the  unequal  growth  of  the  two  bones.  The  deformity  may  be 
treated  by  resecting  a  segment  of  the  longer  bone,  thus  shortening  it.  Oilier 
has  operated  in  a  more  scientific  fashion.  He  cuts  down  upon  the  epiphyseal 
cartilage  whose  active  growth  is  producing  the  deformity  and  destroys  it  in  part 
or  completely.  In  the  forearm  bones  the  fertile  epiphyseal  cartilages  are  at  the 
inferior  extremity  of  the  bones;  in  the  tibia  the  fertile  cartilage  is  superior. 


8-.  I 


CHAPTER  LXXIV. 


OSTEOTOMY. 

SPECIAL  INSTRUMENTS  REQUIRED. 

I.  Chisels. — Although  for  many  purposes  the  ordinary  carpenter  chisel, 
tempered  to  cut  hard  wood,  is  convenient  and  efficacious,  yet  most  surgeons 
prefer  an  instrument  fashioned  out  of  piece  of  metal;  of  these  there  are  in- 
numerable patterns.  All  chisels  ought  to  be  large  enough  to  aflford  a  good 
grasp  to  the  surgeon's  hand,  such  as  are  so  small  as  to  recjuire  handling  by 


Fig.  971. — Chisel. 

the  fingers  and  thuml)  are  difficult  to  use  with  precision.  The  most  useful 
chisel  has  a  cutting  edge  1/2  inch  wide;  a  narrower  instrument  is  also  serviceable. 

Chisels  are  of  three  varieties: 

(A)  The  ordinary  chisel  with  beveled  edge.  This  is  suitable  for  paring  or 
shaving  bone  and  for  excising  wedges  of  bone.  Figures  971  and  972  show 
why  ordinary  chisels  are  not  fitted  to  make  linear  incisions  in  bone. 


// 


Chisel. 


Osteotome. 


Fig.  972. 


(B)  Gouges  of  various  shapes  are  useful  especially  for  the  cutting  of  gutters 
or  grooves  in  bone.  Their  cutting-edge  should  be  beveled  on  the  convex  or  outer 
side  (Fig.  973). 

(C)  Osteotomes,  or  wedge-shaped  chisels,  are  the  only  chisels  suitable  for 
making  a  clean  cut  into  or  through  a  bone.     Macewen's  osteotomes,  in  three 

8-,2 


CHISELS. 


833 


sizes  (Fig.  974),  are  classical  and  efficient.     Various  surgeons  have  modified 
Macewen's  osteotomes,  but  only  in  non-essential  details. 

2.  Mallet. — A  mallet  is  a  necessary  adjunct  to  the  chisel.  Wooden  mallets 
are  excellent,  but  are  liable  to  split  after  having  been  boiled  frequently.  Figure 
975  shows  how  a  leaden  mallet  becomes  spoiled  by 
use.  A  heavy  wide-faced  bronze  mallet  is  efficient 
and  durable.  Many  surgeons  use  an  ordinary  steel 
hammer.  In  an  emergency  any  block  of  wood  or  a  potato  masher  serves  every 
purpose  and  is  easily  sterilized  by  boiling.  Rawhide  mallets  are  usually  too 
light  and  do  not  withstand  boiling  satisfactorily. 


Fig.  973. 


Fig.  974. 

METHODS  OF  USING  CHISELS. 

In  osteotomy  the  old  saying,  "the  more  haste,  the  less  speed,"  holds  true. 
One  should  work  systematically.  In  cutting  out  a  wedge-shaped  piece  from 
a  bone  one  is  tempted  to  insert  the  chisel  and  make  it  penetrate  to  the  full 
depth  of  the  cut  which  must  be  made.  If  one  does  this,  the  chisel  will  surely 
be  jammed  and  gripped  in  the  bone,  causing  trouble  and  loss  of  time.  One 
should  content  one's  self  by  merely  cutting  through  the  external  layer  of  hard 


Fig.  975. 

a,    Lead    mallet;    face    mushroomed    from    use;  b,  large  bronze  mallet;  c,  wooden  mallet; 

d,  Mixter's  mallet  of  vulcanized  fibre. 

bone  until  the  whole  wedge  is  outlined  and  then  step  by  step  penetrate  more 
deeply.  Macewen,  who  is  a  past  master  in  the  use  of  the  chisel,  seizes  it  low 
down  in  the  palm  of  the  left  hand:  so  low,  in  fact,  that  the  ulnar  side  of  the  hand 
is  supported  by  the  patient's  body,  the  thumb  of  the  left  hand  being  extended 
up  the  chisel  with  its  tip  resting  against  the  under  surface  of  the  expanded  head 
of  the  handle  (Fig.  976).  The  object  of  this  is  to  prevent  any  too  sudden  and 
53 


834  OSTEOTOMY. 

great  onward  movement  of  the  instrument,  e.  g.,  when  passing  from  cortical 
to  cancellous  bone.  Whenever  a  few  taps  of  the  mallet  have  caused  the  in- 
strument to  penetrate  a  short  distance  into  the  bone  it  must  be  slightly  withdrawn 
so  as  to  avoid  jamming.  Slight  pressure  upwards  with  the  left  thumb  generally 
suflBces;  often,  however,  a  little  lateral  motion  given  the  chisel  will  aid.  Back- 
ward and  forward  motion  of  the  instrument  it  not  permissible:  such  motion  is 
liable  to  break  it. 


Fig.  976. — (Tubby.) 

In  preparing  for  an  osteotomy  the  part  to  be  operated  upon  must  rest  on  a 
sand-bag  and  should,  if  possible,  be  so  placed  that  the  chisel  cuts  away  from 
important  soft  parts  and  toward  the  surgeon.  The  surgeon  can  work  more 
accurately  cutting  toward  than  away  from  himself. 

The  size  of  the  wound  in  the  soft  parts  depends  on  the  work  to  be  done  and 


Fig.  977. — Adams'  saw. 

the  dexterity  of  the  surgeon.  The  educated  hand,  using  the  chisel  as  a  probe, 
is  independent  of  the  assistance  of  the  eye.  It  is  safer  for  those  who  have  not 
had  large  experience  to  make  an  external  wound  sufficiently  large  to  allow  of  the 
eye  supervising  the  work. 

When  section  of  a  large  and  strong  bone  is  contemplated,  three  sizes  of 


OSTEOTOMY. 


835 


osteotome  should  be  provided.  The  thickest-bladed  instrument  is  used  first. 
When  this  has  penetrated  the  bone  to  such  a  depth  that  its  thickness  causes 
it  to  become  jammed,  it  is  replaced  by  the  next  finer  instrument  which  suffers 
no  obstruction  from  the  sides  of  the  cut  made  by  the  previous  osteotome. 


Fig.  978.— Jones'  saw.     Note  button  on  point. 

3.  Saws. — Saws  are  frequently  used  instead  of  chisels  for  dividing  bone. 
The  ordinary  surgical  saws,  such  as  are  used  in  amputations,  are  unsuitable  for 
osteotomy.     Undoubtedly  Adams'  saw  (Fig.  977),  or  Jones'  modification  of  it 


Fig.  979. 

(Fig.  978),  is  the  best  pattern.     The  ordinary  "finger  saw"  is  also  useful 
(Fig.  979). 

Chain  saws  have  been  much  used  for  the  division  of  bone,  but  they  are 


Fig.  980. — Gigli  saw. 

expensive,  easily  broken,  difficult  to  handle  and  are  now  practically  displaced 
by  the  simpler  and  more  efficient  wire  saw  of  Gigli  (Fig.  980). 


METHODS  OF  PERFORMING  OSTEOTOMY. 

I,  Linear  Osteotomy. — Macewen's  supra-condyloid  osteotomy  for  knock- 
knee  is  a  classical  example  of  linear  osteotomy  and  will  be  taken  as  the  type  of 
such  operations. 


Ss6 


OSTEOTOMY. 


I.  Administer  a  general  anaesthetic.  Render  the  limb  bloodless  and  apply  the 
elastic  constrictor.  Place  the  patient  on  his  back,  arrange  the  limb  to  be  oper- 
ated on  so  that  it  lies  with  the  outer  side  of  the  knee  and  lower  part  of  the  femur 
resting  on  a  sand-bag.  The  best  sand-bag  is  one  of  stout  cloth  about  i8  x  12 
inches  in  size,  and  moderately  (not  tightly)  filled  with  sand  (Fig.  981).     The 


Fig.  981. — (Labey.) 


surgeon  stands  on  the  affected  side  of  the  patient.     An  assistant  fixes  the  limb 
by  grasping  the  tibia  and  the  upper  part  of  the  femur. 

Step  I. — ^Draw  an  imaginary  line  transversely  one  finger's  breadth  above 
the  superior  tip  of  the  external  condyle.  Draw  an  imaginary  vertical  line 
longitudinally  1/2  inch  in  front  of  the  adductor  magnus  tendon  (adductor 
tubercle).     Note  the  point  where  these  lines  cross.     At  this  point  introduce  a 

long-bladed  scalpel  or  bistoury  directly 
to  the  bone  and,  cutting  upward,  make 
a  longitudinal  incision  of  such  size  as  to 
admit  the  largest  osteotome.  Endeavor 
not  to  wound  the  periosteum. 
Step  2. — (A)  Hold  the  knife  in  situ. 
Pass  the  largest  osteotome  (of  Macewen's 
series)  alongside  the  knife,  down  to  the 
bone.  Turn  the  blade  of  the  osteotome 
transversely  to  the  bone  (Fig.  982).  Pass  the  edge  of  the  osteotome  over 
the  bone  until  it  reaches  the  posterior  internal  border  and  make  it  penetrate 
the  bone  from  behind  forwards  and  towards  the  outer  side.  After  the  cortical 
bone  is  penetrated,  pass  a  finer  osteotome  along  the  face  of  the  first  one  used  and 
remove  the  latter.     The  wide  groove  left  by  the  passage  of  the  coarser  gives 


(Maceiven.) 


OSTEOTOMY. 


837 


great  delicacy  and  precision  to  the  use  of  the  more  deHcate  instrument.  With 
this  finer  instrument  complete  the  section  of  the  femur  along  the  line  described, 
to  a  point  near  the  outer  layer  of  cortical  bone.  It  is  wise  not  to  divide  the 
outer  layer  of  bone  with  the  osteotome. 

(B)  Partially  withdraw  the  osteotome.  Change  the  direction  of  its  cutting- 
edge  and  make  it  cui  through  the  whole  cortical  bone  on  the  inner  side  of  the 
femur  (Fig.  983). 

(C)  Once  more  change  the  direction  of  the  osteotome  and  with  it  cut  the 
bone  from  its  anterior  inner  toward  but  hot  to  its  posterior  external  borders. 
Of  course  in  many  cases,  e.  g.,  in  children  the  first  line  of  bone  section  is  all 
that  is  required,  but  in  others  where  the  bone  is  large,  the  above  systematic 


— ""^i-f — I ; —  c* — 


Fig.  983. — Original  lines  of  section  of  the  femur  in  osteotomy. 


procedure  will  be  found  expeditious  and  safe.  The  osteotome  ought  not  to  be 
removed  from  contact  with  the  bone  until  the  bone  section  is  completed,  as  its 
reintroduction  through  the  small  incision  in  the  soft  parts  is  a  matter  of  much 
difficulty.  All  the  procedures  described  can  be  carried  out  through  a  small 
wound. 

Step  3. — Remove  the  osteotome.  Cover  the  wound  with  an  aseptic  pad. 
With  one  hand  grasping  the  femur  at  the  site  of  operation  and  the  other 
grasping  the  leg,  complete  the  rectification  of  the  deformity  by  breaking  or 
bending  the  partially  divided  femur. 

Step  4. — Apply  dressings.  Remove  the  elastic  constrictor.  Treat  as  a 
simple  fracture  of  the  femur.  Both  limbs  are  usually  operated  upon  at  the 
same  sitting. 

II.  Cuneiform  Osteotomy. — The  operation  as  performed  for  angular 
anterior  curvature  of  the  tibia  may  be  taken  as  typical.  ,  Render  the  limb 
bloodless.  Apply  an  elastic  constrictor  (some  surgeons  omit  this  precaution 
as  they  fear  increased  subsequent  oozing). 

Step  I. — Make  a  longitudinal  incision  down  to  the  bone  over  the  most 
prominent  part  of  the  tibia.  This  cut  need  not  be  much  longer  than  the  width 
of  the  chisel,  as  the  wound  in  the  soft  parts  can  easily  be  made  to  slide  in  various 


838 


OSTEOTOMY. 


directions  to  expose  different  portions  of  the  bone.     Reflect  the  periosteum 
with  the  soft  parts.     Keep  the  wound  open  with  retractors. 

Step  2. — With  an  ordinary  chisel  outline  the  base  of  a  wedge  by  cutting 
through  the  cortical  bone.  This  base  corresponds  to  the  apex  of  the  angular 
deformity  (Fig.  984)  and  should  be  smaller  than  that  which  it  is  believed  will 
be  necessary.  With  the  chisel  cut  through  the  cancellous  bone  and  remove  a 
wedge-shaped  portion  of  bone.  Do  not  cut  through  the  whole  thickness  of  the 
bone;  the  posterior  undivided  portion,  corresponding  to  the  apex  of  the  wedge, 
is  easily  fractured  by  manual  force.  Straighten  the  limb.  If  sufficient  bone 
has  not  been  removed,  it  is  easy  to  slice  off  more 
with  the  chisel  until  the  minimum  amount  which 
permits  of  correction  has  been  removed.  If  the 
fibula  interferes  with  the  correction  it  must  be  bent 
or  broken  by  manual  force  or  divided  with  an 
osteotome. 

Step  3. — If  the  wound  tends  to  gape,  introduce  a 
few  sutures.  Apply  aseptic  dressings.  Immobilize. 
It  is  well  to  elevate  the  limb  for  twenty-four  hours  or 
longer.  The  subsequent  treatment  is  the  same  as 
for  simple  fracture. 

III.  Subcutaneous  Osteotomy  by  Means  of  a 
Saw. — A  good  type  of  this  operation  is  that  of  W. 
Adams  for  the  intra-capsular  division  of  the  neck  of 
the  femur  in  cases  of  anchylosis  in  bad  position. 
Fig.  984.  Step  i. — Introduce  a  long,  narrow- bladed  knife 

(Fig.  985)  at  a  point  one  finger's  breadth  above  the 
top  of  the  trochanter  major,  and  push  it  on  until  it  encounters  the  neck  of  the 
femur,  over  which  it  must  be  passed  in  a  direction  at  right  angles  to  the  axis  of 
the  neck.  The  route  taken  by  the  knife  is  practically  one  parallel  to  Poupart's 
ligament.     Leave  the  knife  in  situ. 

Step  2. — Pass  an  Adams'  or  Jones'  saw  alongside  of  knife  until  the  teeth  of 
the  saw  are  in  contact  with  the  femoral  neck  (Fig.  986).     Remove  the  knife. 


Fig.  985. 

With  the  saw  divide  the  bone.  While  sawing  one  is  liable  to  pull  Adams's 
saw  out  of  the  cut  in  the  bone  and  have  much  difficulty  in  reintroducing  it. 
The  hook  or  beak  on  Jones'  saw  prevents  such  an  accident.  Before  obtaining 
complete  rectification  it  may  be  necessary  to  divide  the  tendons  of  the  adductor 
longus,  sartorius  and  perhaps  the  rectus  muscles. 

Step  3. — Apply  aseptic  dressings.     Immobilize  the  limb  in  a  position  of 
slight  flexion  and  abduction. 


KNOCK-KNEE.  839 

Genu  Valgum.  Knock-knee. — There  are  three  bony  deformities  com- 
monly present  in  knock-knee. 

(i)  Difference  in  size  of  the  condyles,  i.  e.,  elongation  of  the  internal  one. 

(2)  Bending  of  the  lower  end  of  the  diaphysis  of  the  femur.  Macewen  found 
this  in  120  out  of  166  affected  bones.  In  some  cases  the  same  effect  is  obtained 
without  true  bending  of  the  bone,  by  an  elongation  of  the  inner  side  of  the  femur 
which  naturally  pushes  down  the  inner  portion  of  the  epiphysis. 

(3)  Bending  of  the  upper  end  of  the  tibial  diaphysis.  The  most  important 
deformity  in  knock-knee  is  the  bending  of  the  lower  end  of  the  femur,  but  all 
the  deformities  mentioned  have  had  operations  devised  for  their  correction. 

Osteotomy  for  the  correction  of  genu  valgum. 

(A)  Macewen's,  directed  against  the  bending  of  the  lower  end  of  the  femur 
(seep.  835). 

(B)  Supra-condyloid  osteotomy  as  done  in  the  New  York  Hospital  for 
Ruptured  and  Crippled  (Whitman,  "Orthop.  Surg.,"  421): 


Fig.  986. 

Place  the  inner  surface  of  the  semiflexed  knee  on  a  sand-bag.  Grasp  the 
femur  above  the  condyles  and  pass  a  sharp  osteotome  about  the  size  of  a  lead- 
pencil  through  all  the  soft  structures  down  to  the  bone  at  a  point  i  1/2  inches 
above  the  external  tuberosity.  The  cutting-edge  of  the  osteotome  must  be 
kept  parallel  to  the  long  axis  of  the  thigh  until  it  comes  in  contact  with  the  bone 
when  it  is  to  be  turned  transversely  to  the  bone.  Drive  the  osteotome  through 
the  cortical  bone  until  so  much  is  divided  that  the  remainder  is  easily  fractured. 
The  rest  of  the  treatment  is  the  same  as  in  Method  A. 

Inspection  of  figures  987,  988,  989,  shows  that  theoretically  Macewen's 
operation  is  the  better,  but  it  must  be  admitted  that  a  clean  osteotomy  gives 
good  results  whether  performed  from  the  inner  or  the  outer  side. 

(C)  Ogston's  operation:  Osteo-arthrotomy. — This,  the  first  successful 
operation  for  knock-knee  (1876),  is  directed  against  the  real  or  supposed  length- 
ening of  the  internal  condyle. 


840 


OSTEOTOMY, 


Step  I. — Flex  the  knee  as  fully  as  possible.  Introduce  a  narrow-bladed 
knife  or  elongated  tenotome  (Adams's  knife)  through  the  skin  at  a  point  2  or  3 
inches  above  the  tip  of  the  inner  condyle.  Push  the  knife  downwards,  forwards 
and  outwards  until  the  point  is  felt  in  the  intercondyloid  space.  Turn  the  edge 
of  the  knife  towards  the  bone  and  in  withdrawing  it  cut  the  soft  structures  to  the 
bone. 

Step  2. — Introduce  an  Adams's  saw  through  the  knife  wound  and  divide  the 
internal  condyle  from  above  downwards  for  three-fourths  of  its  thickness.  Com- 
plete the  fracture  by  straightening  the  limb,  when  the  loosened  condyle  will 
slip  upwards  (Fig.  990). 

Step  3. — Immobilize  and  treat  as  a  fracture. 

{D)  Reeves'  operation  is  similar  to  Ogston's  but  in  it  the  bone  section  is 
made  with  a  chisel  down  to  but  not  through  the  articular  cartilage,  thus  avoiding 


Fig.  987. — {Macewen.) 


Fig.  988. — (Macewsn.)  Fig.  989. — {Macewen.) 


any  direct  opening  of  the  joint.  Fowler  and  Pilcher  long  ago  showed  that  this 
operation  has  nothing  to  recommend  it. 

(£)  Chiene's  operation  differs  from  Ogston's  in  that  he  removes  with  the 
chisel  a  wedge  of  bone  from  the  base  of  the  condyle.  The  operation  is  un- 
necessarily difficult. 

(F)  Section  of  Tibia. — Step  i. — On  the  inner  surface  of  the  tibia,  midway 
between  its  anterior  and  posterior  borders  make  a  longitudinal  incision  down 
to  the  bone.  The  cut  should  be  only  large  enough  to  easily  admit  the 
osteotome. 

Step  2. — Introduce  the  osteotome  and  turn  its  cutting  edge  transversely  to  the 
bone.  Divide  the  tibia  from  within  outwards.  "  commencing  from  the  posterior 
border  and  raising  the  osteotome  gradually  up  until  it  comes  into  contact  with 
the  anterior  surface  of  the  lower  portion  of  the  tubercle,  which  is  by  far  the  most 
dense  portion"  (Macewen).  Next  divide  the  dense  bone  on  the  outer  side  of 
the  tibia  from  before  backwards.  Complete  the  fracture  by  manual  force.  It 
is  unnecessary  to  divide  the  fibula. 


OSTEOCLASIS    IN    GENU    VALGUM. 

OSTEOCLASIS  IN  GENU  VALGUM. 


841 


(A)  Manual. — Administer  a  general  anaesthetic.  Place  the  patient  on  his 
back.  Let  an  assistant  firmly  grasp  and  steady  the  upper  portion  of  the  thigh. 
With  one  hand  grasp  the  femur  immediately  above  the  deformity,  ■ndth  the  other 


Fig.  990. — {Hoffa.) 

a,  Annandale;  b,  Ogston;  c,  Reeves;  d,  Macewen's  cuneiform  osteotomy;  e,  Chiene;  /,  ISIac- 

ewen's  supra-condyloid ;  g,   Reeves;  h,   Billroth;  i,  Mayer;  k,   Schede;  /,   Barwell. 

hand  grasp  the  leg.  Fully  extend  the  knee  and  endeavor  forcibly  to  bring  the 
limb  into  a  straight  position.  When  correction  is  obtained  it  is  usually  due  to 
the  production  of  one  or  several  of  the  following  lesions:  Fracture,  green  stick 
or  complete,  of  the  lower  end  of  the  femur;  separation  of  the  femoral  or  tibial 
epiphysis  or  of  both;  fracture  of  the  internal  condyle  (as  produced  in  Ogston's 
operation) ;  rupture  of  the  external  lateral  ligament. 


842  OSTEOTOMY. 

(B)  Instrumental  Osteoclasis.— This  operation  as  applied  to  knock-knee 
is  carried  out  in  much  the  same  manner  as  in  the  case  of  bow-leg  and  hence 
requires  no  description  here. 

Indications  for  Operation  in  Knock-knee. — Mechanical  treatment  by 
massage  and  apparatus  often  gives  good  results  in  moderate  degrees  of  deformity 
in  patients  under  four  years  of  age.  After  the  fourth  year  improvement  cannot 
be  expected  from  other  than  operative  treatment,  hence  operation  is  pos\J;ively 
indicated  in  every  case  of  knock-knee  where  the  patient  is  over  four  years  of  age, 
where  disability  is  present,  provided  that  the  general  health  of  the  patient  is 
fairly  good.  The  operation,  being  practically  without  danger,  is  permissible  for 
aesthetic  reasons  in  patients  whose  health  is  good. 

Choice  of  Operation. — Osteoclasis. — Theoretically,  the  danger  of  epiphy- 
seal separation  causing  subsequent  want  of  bone  development  is  a  serious 
objection  to  osteoclasis,  but  experience  seems  to  show  that  these  dangers  have 
been  much  exaggerated.  Osteoclasis  is  only  suitable  in  the  very  young  where 
the  bones  are  still  soft.  On  the  whole,  however,  osteoclasis  whether  manual 
or  instrumental  is  very  inferior  to  osteotomy  in  that  it  produces  more  injury  than, 
and  lacks  the  definiteness  of  the  latter  operation. 

Osteotomy. — Only  when  the  tibial  curvature  is  much  greater  than  the  fem- 
oral does  the  former  require  division.  This  is  a  rarity.  In  very  rare  and  ex- 
aggerated cases  osteotomy  both  of  the  tibia  and  of  the  femur  may  be  performed, 
although  in  these  circumstances  femoral  osteotomy  plus  division  of  the  biceps 
tendon  has  given  as  good  or  better  results  than  double  osteotomy.  All  other 
osteotomies  for  knock-knee  have  been  practically  superseded  by  the  Macewen 
supra-condyloid  operation  or  some  modification  of  it. 


CHAPTER  LXXV. 


BOW-LEG.  GENU  VARUM. 


Typical  genu  varum  is  the  result  of  external  bowing  of  the  femur  and  of 
the  leg  bones.  The  maximum  curve  is  generally  near  the  knee.  Bow-leg  may 
be  the  result  of  lateral  bending  of  the  leg  bones  alone,  the  femur  being  unaltered. 
An  anterior  curvature  of  the  tibia  gives  another  form  of  bow-leg.  Operative 
correction  is  demanded  in  all  severe  cases.  Before  the  age  of  four  or  five  years 
mild  deformities  may  be  corrected  by  mechanical  appliances;  after  that  age, 
operation  affords  the  only  prospect  of  cure. 

Methods  of  Operating. — (I)  Linear  Osteotomy. — Note  which  bone  or 
bones  are  most  seriously  affected.  Usually  in  typical  genu  varum  both  the 
femur  and  tibia  are  badly  curved.  Note  which  part  of  the  individual  bone 
is  most  bent;  it  is  this  part  which  must  be  divided. 

(a)  If  osteotomy  of  the  middle  third  of  the  femur  is  indicated,  make  a  vertical 
incision  through  the  soft  parts  down  to  the  bone  on  the  outer  or  antero-external 
side  and  proceed  as  in  supra-condylar  osteotomy,  in 
this  case,  however,  cutting  the  bone  from  without 
inwards.  (b)  If  the  tibia  is  most  affected,  incise 
vertically  the  soft  parts  down  to  the  bone  over  the 
inner  surface  of  the  bone  at  the  point  of  greatest 
curvature.  Introduce  the  osteotome  and  then  turn 
it  transversely  to  the  bone  and  divide  the  cortical 
bone  of  the  inner  and  outer  sides  of  the  tibia,  and 
especially  that  of  the  anterior  margin.  Be  careful 
not  to  injure  the  anterior  tibial  vessels  and  nerves 
which  lie  close  to  the  outer  surface  of  the  bone. 
Fracture  the  posterior  layer  of  cortical  bone  by 
manual  force.  Forcibly  fracture  or  bend  the  fibula. 
If  this  is  impossible,  palpate  the  fibula  and  make 
a  small  incision  down  to  it  through  the  soft  struc- 
tures of  the  outer  side  of  the  leg.  Introduce  a  very 
narrow  osteotome  and  divide  the  bone,  (c)  If  femur 
and  tibia  are  both  markedly  curved,  operate  on  both  at  the  same  sitting. 

Note. — The  object  of  the  surgeon  is  to  correct  the  deformity.  If  division 
of  one  bone  is  insufficient,  then  divide  the  other  as  well;  if  this  is  insufficient 
repeat  the  operation  at  whatever  places  it  may  be  demanded.  Macewen  has 
performed  lo  osteotomies  on  the  same  patient  at  the  same  sitting  and  obtained 
a  good  result. 

843 


Fig. 


991. 


844  BOW-LEG.       GENU    VARUM. 

II.  Cuneiform  osteotomy  is  ])articularly  suitable  in  cases  of  anterior 
curvature  of  the  tibia  (sec  p.  837). 

III.  Oblique  Osteotomy  (Oilier). — In  some  cases,  especially  of  anterior 
curvature  of  the  tibia  where  there  is  much  shortening,  oblique  division  of  the 
bone   (Fig.  991)    permits  elongation.     To   attain   this   elongation   it   may   be 


Fig.  992. — -Grattan's  osteoclast. 


Fig    99^  — Collins  osteoclast 

necessary  to  lengthen  the  tendo  Achillis  by  means  of  any  one  of  the  well-known 
methods. 

IV.     Osteoclasis. 

(A)  Manual. — Grasp  the  bone  affected  above  and  below  the  point  of  the 
greatest  curvature  and  bend  it  straight  or  produce  a  fracture.  In  the  very 
young  a  green-stick  fracture  is  a  desirable  lesion  to  produce.     It  is  often  neces- 


OSTEOCLASIS.  845 

sary  to  support  the  point  of  greatest  convexity  on  a  fulcrum  {e.g.,  a  padded 
wedge  of  wood)  before  sufficient  force  can  be  applied.  It  may  be  necessary  to 
produce  mutiple  fractures. 

(B)  Instrumental. — The  necessary  fracture  or  bending  may  be  more  pre- 
cisely and  definitely  produced  by  means  of  an  osteoclast.  Probably  Grattan's 
osteoclast  (Fig.  992)  is  the  best.  Place  the  limb  in  the  instrument  in  such  a 
fashion  that  the  movable  arm  (a)  is  applied  to  the  point  of  greatest  convexity 
while  the  opposite  or  concave  side  of  the  limb  is  supported  by  the  two  parallel 
fLxed  arms  of  the  osteoclast.  By  means  of  the  screw  (x)  make  a  movable  arm 
(a)  press  against  and  fracture  the  limb.     Fig.  993  shows  Collin's  osteoclast. 

By  whichever  means  the  limb  is  straightened,  it  must  be  fixed  in  good  position 
by  plaster  of  Paris  or  apparatus  and  treated  as  an  ordinary  fracture.  In  the 
treatment  of  bow-legs  osteotomy  and  osteoclasis  seem  to  give  about  equally 
good  results. 


CHAPTER  LXXVI. 

OPERATIONS  ON  THE  PELVIC  BONES. 

Operations  on  the  bones  of  the  pelvis  are  indicated  in  acute  osteomyelitis; 
tuberculosis;  sarcoma  etc. 

1.  Acute  Osteomyelitis  and  Periostitis. — The  method  and  time  of  opera- 
tion must  vary  according  to  circumstances.  "In  the  severest  cases  with  high 
fever,  great  local  pain  and  sv^^elling  an  incision  should  at  once  be  made  at  the 
point  of  greatest  tenderness  or  swelling"  (Tillmanns),  all  requestra  and  diseased 
bone  removed  and  drainage  provided.  When  the  disease  is  on  the  outer  side 
of  the  ilium  the  above  advice  is  easily  carried  out,  when  however  the  disease 
is  principally  on  the  inner  side  of  the  bone  it  is  necessary  to  trephine  or  better 
to  excise  a  larger  or  smaller  amount  of  the  ilium  in  order  to  provide  proper 
drainage.  To  do  this  the  author  has  found  it  necessary  to  operate  several 
times,  in  an  individual  case.  When  there  is  extensive  disease,  extensive  ex- 
posure of  the  bone  is  necessary. 

When  the  inflammation  and  swelling  is  diffuse  and  fever  is  high  more  system- 
atized resection  of  bone  is  necessary  and  the  whole  affected  bone  should  be  early 
removed.  When  the  local  and  general  symptoms  of  the  disease  are  mild,  non- 
operative  treatment  should  be  adopted  until  recovery  takes  place  or  the  incidence 
of  abscess  or  threatening  symptoms  indicate  operation. 

2.  Chronic  pyogenic  osteomyelitis  with  fistula  calls  for  operation 

3.  Tuberculous  osteomyelitis  is  usually  situated  near  and  commonly  involves 
one  of  the  joints  so  that  the  treatment  is  generally  directed  primarily  against 
the  arthritis  (hip-joint  disease;  sacro-iliac  disease). 

4.  Neoplasms.  All  malignant  neoplasms  demand  excision  provided  there 
is  a  moderate  chance  of  success.  All  non-malignant  neoplasms  threatening 
life  from  pressure  etc.,  similarly  demand  removal.  All  other  neoplasms  de- 
mand removal  provided  that  the  operation  is  not  one  of  much  gravity.  The 
usual  rule  of  very  wide  excision  prevails  in  operations  for  malignant  tumors; 
when  removing  such  neoplasms  as  osteomata  and  chondromata  a  portion  of  the 
pelvis  itself  ought  to  be  removed  to  make  sure  that  the  base  of  the  neoplasm  is 
not  left. 

Every  extensive  operation  on  the  ilium  requires  free  exposure  of  the  bone 
This  may  be  obtained  in  various  but  similar  ways. 

A.  Sprengel's  method. — Make  an  incision  from  the  anterior  superior 
spine  of  the  ilium,  downwards  along  the  anterior  border  of  the  tensor  vaginae 
femoris  and  divide  the  deep  fascia  (Fig.  994).  From  the  upper  end  of  the  in- 
cision cut  backwards  along  the  iliac  crest  dividing  the  fascia  and  the  origin  of 
the  gluteus  medius  and  minimus. 

846 


PELVIC   BONES. 


847 


When  the  active  operation  is 


Through  the  above  incision  separate  the  muscles  and  periosteum  from  the 
pelvis  and  retract  them  downwards  and  backwards.  This  gives  good  exposure 
of  the  ilium  and  of  part  of  the  acetabulum.  Through  this  incision  Kocher 
removed  an  exostosis  from  the  acetabulum, 
finished,  the  flap  is  easly  replaced. 

B.  Larghi's  Method     (see  p.  861). 

C.  Kocher's  Method. — Kocher  excised 
one  half  of  the  pelvis  for  sarcoma  as  follows: 

Step  I. — Make  an  incision  from  the  sarco- 
iliac  synchondrosis  forwards  along  the  iliac 
crest  and  Poupart's  ligament. 

Step  2. — Divide  the  abdominal  muscles  at- 
tached to  the  iliac  crest  and  Poupart's  ligament; 
separate  the  transversalis  fascia  and  peritoneum 
from  the  tumor  until  the  iliac  vessels  are  ex- 
posed. Retract  the  iliac  vessels  and  the  anterior 
crural  nerve  inwards. 

Step  3. — Isolate  and  divide  the  muscles 
passing  under  Poupart's  ligament  external  to 
the  great  vessels.  Divide  the  rectus  femoris, 
sartorius,  tensor  vaginse  femoris.  Separate  the 
gluteus  medius  and  minimus  bluntly  from  the 


Fig.  994. 


Fig.  995. — (Kulenkamff.) 
Anteriorly  divide  the  Ilio- 


ilium  until  the  sacro-iliac  articulation  is  reached, 
psoas  muscle  and  the  capsule  of  the  hip-joint. 

Step  4. — Divide  the  horizontal  ramus  of  the  pubis  and  the  ascending  ramus 
of  the  ischium. 

Separate  the  sacro-iliac  articulation  and  dislocate  the  bone  downwards. 

Step  5. — Separate  the  rest  of  the  pelvic  attachments  by  blunt  and  sharp  dis- 


848 


OPERATIONS    ON    THE    PELVIC    BONES. 


section.  The  flexors  arising  from  the  tuber  ischii  and  the  sacro-sciatic  ligaments 
require  division.  Excise  the  head  of  the  femur.  Remove  the  mobihzed  portion 
of  pelvis. 

Step  6. — Suture  the  abdominal  muscles  to  the  glutei.  Close  the  wound  by 
deep  and  superficial  sutures  after  providing  freely  for  drainage. 

Kocher  remarks  that  the  bleeding  is  only  moderate  as  no  large  vessels  are 
injured  but  that  it  might  be  well  to  ligate  the  internal  iliac  vessels  before  re- 
tracting them  in  Step  2. 

D.  Kulenkamff's  Method. — Step  i. — Secure  temporary  hemostasis  by 
Momberg's  method.  Make  an  incision  along  the  crest  of  the  ilium  and  Poupart's 
ligament.  Separate  the  iliacus  muscle  (if  it  is  not  involved  in  the  disease)  and 
retract  it  along  with  the  iliac  vessels  inwards. 

Step  2. — Perpendicularly  to  the  first  incision  make  a  cut  reaching  down  to  the 
trochanter  major.     Open  the  hip-joint  and  decapitate  the  femur. 

The  rest  of  the  operation  is  practically  the  same  as  Kocher's.  Figure  995 
shows  the  result  obtained  by  Kulenkamff's  (Beitriige  z.  klin.  Chir.,  Ixviii,  768). 


Fig.  9g6 


Fig.  997. 


Excision  of  Symphysis  Pubis, — Tuberculous  osteomyelitis  affecting  the 
pubic  bones  and  the  symphysis  calls  for  early  operation.  The  disease  may  be 
exposed  by  an  incision  directly  over  it ;  all  affected  bone  cut  away  with  chisel  and 
mallet  and  all  abscesses  opened  and  curetted.  If  no  distinct  and  separated 
sequestra  is  present  v.  B  linger  recommends  that  a  transverse  incision  be  made 
immediately  above  the  pubis,  the  soft  parts  separated  and  the  bone  divided 
subperiosteally  beyond  the  disease  (Fig.  996). 

The  results  of  the  operative  treatment  of  pubic  tuberculosis  are  good. 

Excision  of  the  Acetabulum. — Schmidt's  Method,— 5/e^  i. — Open  the 
hip  joint  through  Langenbeck's  incision  (p.  835).  Dislocate  the  head  of  the 
femur  (if  necessary  excising  it). 

Step  2. — Adduct  and  rotate  the  limb  outwards.  From  the  middle  of  the 
wound  make  a  cut  at  right  angles  forwards  towards  the  anterior  inferior  iliac 
spine.     This  cut  penetrates  to  the  bone.     By  blunt  dissection  separate  the  peri- 


EXCISION  ACETABULUM.  849 

osteum  and  overl3dng  soft  parts  from  the  ilium  above  the  acetabulum  from  the 
anterior  inferior  spine  to  the  sciatic  notch. 

Step  3. — With  chisel  and  mallet  divide  the  ilium  transversely  above  the  ace- 
tabulum (Fig.  997).     Be  careful  not  to  injure  the  pelvic  contents. 

Step  4. — Divide  the  horizontal  ramus  of  the  pubis  with  a  Gigli  wire  saw. 

Step  5. — With  a  periosteal  elevator  separate  the  soft  parts  from  the  ischium 
below  the  acetabulum.  Divide  the  ischium  with  a  Gigli  saw  or  a  chisel 
(Fig.  997). 

Step  6. — Seize  the  acetabulum  with  bone  forceps  and  remove  it,  dividing  any- 
obstructing  connections  with  scissors. 

Step  7. — Provide  for  drainage.  Close  the  wound.  Dress.  Put  up  in  a 
position  of  marked  abduction. 


54 


CHAPTER    LXXVII. 
SACRO-ILIAC  DISEASE. 

Jacobson  and  Rowlands  ("Operations  of  Surg.,"  ii,  874)  write: 

"It  has  been  shown  that  the  prognosis  in  this  disease,  usually  looked 
upon  as  so  grave,  is  much  better  if  the  same  radical  methods  of  treatment, 
which  have  proved  so  satisfactory  in  other  joints,  are  applied  to  the  sacro- 
iliac  synchondrosis." 

Mr.  Collier  first  drew  attention  to  the  above  fact  with  a  case  successfully 
treated  by  trephining  (Lancet,  1889,  vol.  ii,  p.  787),  and  Mr.  Makins  and 
Mr.  Golding  Bird  followed,  each  surgeon  publishing  three  successful  cases 
("Clin.  Soc.  Trans.,"  vol.  xxvi,  p.  127,  and  vol.  xxviii,  p.  186). 

The  following  points  are  taken  from  these  papers: 

Operation. — The  joint  is  exposed  by  a  crucial  incision  (Makins),  or  by  a 
flap  (Collier,  Golding  Bird).  In  the  words  of  the  last-named  surgeon,  "a 
semicircular  flap  of  skin  and  subcutaneous  tissue  over  the  iliac  area  of  the 
joint,  and  having  its  convexity  corresponding  to  the  posterior  edge  of  the  ilium, 
is  dissected  upwards  and  forwards,  and  the  underlying  glutaei  are  detached. 
The  bone  being  thus  freely  exposed,  a  large  trephine  is  applied  at  the  root  of 
the  posterior  inferior  iliac  spine,  and  in  a  line  drawn  from  the  top  of  that  spine 
to  the  junction  of  the  anterior  with  the  middle  third  of  the  iliac  crest  .  .  . 
The  ilium  at  the  seat  of  operation  is  very  thick,  but  the  disc  of  bone  removed 
should  reach  quite  down  to  the  joint."  The  trephine-opening  is  then  sufficiently 
enlarged,  the  articular  surfaces  cut  away  with  a  gouge  or  forceps  sufficiently 
to  enable  the  surgeon  to  explore  the  pelvis  surface  of  the  joint,  and  to  liberate 
any  pus  lying  on  this  aspect.  The  sharp  spoon,  or  Barker's  flushing  gouge, 
is  then  thoroughly  used,  all  fragments  of  bone,  granulation  tissue,  or  loosened 
cartilage  removed,  and  any  sinuses  present  laid  open.  Sterilized  iodoform 
having  been  next  applied,  the  soft  parts  are  lightly  drawn  together  with  a 
few  sutures.  A  long  outside,  or  a  Thomas's  hip-splint,  should  be  used  at 
first,  but  subsequently  all  that  is  needed  is  a  well-fitting  pelvic  belt,  as  advised 
by  Mr.  Hilton." 

Bardenheuer  and  Picque  ("Journ.  de  Chir.,"  Sept.,  1910)  have  each 
described  more  systematic  methods  of  excising  the  sacro-iliac  joint.  Picque's 
method  is  the  one  described  here. 

Step  I. — Make  a  curved  incision  penetrating  to  the  bone  along  the  posterior 
third  of  the  iliac  crest  and  continued  down  the  border  of  the  sacrum  to  the 
level  of  the  third  postero-external  tubercle.  With  periosteal  elevator  reflect 
the  periosteum  and  superjacent  soft  parts  from  the  outer  surface  of  the  posterior 
portion  of  the  ilium. 

850 


SACRO-ILIAC   DISEASE. 


851 


Step  2. — The  sacro-iliac  joint  is  so  situated  that  to  reach  it  a  portion  of 
the  ilium  must  be  removed  (Fig.  998).  The  excision  of  the  segment  of 
bone  may  be  complete  or  partial. 

(a)  Complete. — With  an  osteotome  divide  the  iliac  bone  vertically  from  the 


Fig.  998. 

crest  down  to  the  outer  and  upper  corner  of  the  great  sciatic  notch  (Fig.  999, 
Picqu^) 

(b)  Partial. — Make  the  vertical  incision  shorter  and  supplement  it  by  a 
transverse  one  (Fig.  999,  Picque)  in  such  a  fashion  as  to  leave  the  sciatic 
notch  intact. 

Having  divided  the  ilium  pry  up  the  fragment  of  bone  with  an  elevator, 


Fig.  999. — (Picque.) 

divide  its  ligamentous  attachments  and  remove  it.  This  removes  the  iliac 
portion  of  the  sacro-iliac  joint  and  freely  exposes  the  articular  and  adjacent 
portions  of  the  sacrum. 

Step  3. — Systematically  with  scoop,  rongeur  forceps  and  chisel  remove  all 
disease  from  the  sacrum.  In  doing  this,  so  shave  away  bone  that  no  irregular 
pits  or  tunnels  are  left  which  would  interfere  with  proper  drainage.     If  the 


552  SACRO-ILIAC    DISEASK. 

disease  extends  to  the  sacral  foramina,  working  in  the  above  systematic  fashion 
permits  the  exposure  and  isolation  of  the  nerve  trunks  which  would  be  ex- 
posed to  much  injury  if  the  curette  was  used  blindly.  The  amount  of  bone 
removed  must  vary  with  the  extent  of  the  disease.  In  one  case,  Picque 
writes,  "the  wound  will  have  a  bony  floor  formed  by  the  anterior  portion  of 
the  wing  of  the  sacrum  united  to  the  ilium  by  the  anterior  sacro-iliac  ligament, 
in  another  case  the  wound  will  penetrate  the  pelvis  exposing  the  sacral  nerve 
trunks,  the  iliac  vessels  and  the  ureter.  Thus  the  resection  of  the  sacrum  like 
that  of  the  ilium  may  be  partial  or  complete."  When  extensive  resection  of 
the  sacrum  is  necessary  it  will  usually  be  found  that  nature  has  already  protected 
the  pelvic  organs  by  a  deposit  of  strong  fibrous  tissue. 

Step  6. — Close  part  of  the  wound  with  sutures  and  pack  the  rest  with  gauze. 
Picque  writes,  "however  thorough  the  resection  has  been,  points  of  caries 
will  always  appear  on  the  surface  of  the  spongy  bone,  interfering  with  cic- 
atrization, there  will  be  exuberant  granulations  from  the  superficial  soft  parts 
and  the  dressings  should  be  made  curette  in  hand."  The  duration  of  post- 
operative treatment  varies  much  (six  weeks  to  three  months — Bardenheuer; 
three  to  eight  months — Picque).  The  author  has  had  no  experience  with  the 
Bardenheuer-Picque  operation  but  it  strikes  him  that  the  use  of  Mosetig's 
iodoform  wax  plug  might  facilitate  healing. 

Results. — Bardenheuer  reports  one  series  of  sixteen  cases  with  69  per  cent, 
recoveries  and  a  second  series  of  four  cases  with  100  per  cent,  recoveries, 
Picque  reports  six  cases  with  66  per  cent,  recoveries. 


CHAPTER  LXXVHI. 
HIP. 

Iodoform  Injection. — Krause  describes  the  introduction  of  the  trocar  and 
cannula  as  follows:  The  trocar  ought  to  be  from  2  3/4  to  3  1/2  inches  in 
length.  The  patient  lies  flat  on  his  back.  Flexion  of  the  thigh  should  be 
avoided  if  possible,  while  abduction  and  external  rotation  must  be  avoided. 
The  thigh  should  be  in  a  position  of  adduction  and  slight  internal  rotation. 
Introduce  the  trocar  at  right  angles  to  the  axis  of  the  femur,  at  a  point  imme- 
diately above  the  tip  of  the  trochanter  major  and  midway  between  its  anterior 
and  posterior  borders.  Push  the  trocar  slowly  onward  until  its  point  strikes  bone 
(the  head  of  the  femur  or  the  neck  near  the  head) .  Adduct  the  limb  strongly ;, 
keeping  the  point  of  the  trocar  constantly  in  touch  with  the  femoral  head, 
push  the  instrument  cautiously  upwards  and  inwards  until  bony  obstruction 
is  again  encountered.  The  point  of  the  instrument  is  now  lying  between  the 
head  of  the  femur  and  the  rim  of  the  acetabulum.  Withdraw  the  stylette  and 
push  the  cannula  still  further  into  the  joint.  The  method  of  injecting,  the 
material  to  be  used  and  the  after-treatment  are  the  same  as  have  been  described 
in  the  chapter  on  operation  upon  the  knee. 

Vaseline  Injections. — Rovsing  ("Annals  Surgery,"  Dec,  1909)  advises 
the  injection  of  sterile  vaseline  into  joints  affected  with  traumatic  dry  arthritis. 
If  any  turbid  fluid  escapes  through  the  cannula  no  injection  of  vaseline  should 
be  made,  a  little  clear  synovial  fluid  escaping  does  not  contraindicate  infection. 
In  the  adult  about  20  c.c.  of  vaseline  is  the  correct  quantity  to  throw  into  the 
hip-joint. 

A  trocar  and  cannula  is  the  proper  instrument  to  employ — a  cannula  with 
cutting-edge  but  no  trocar  is  too  dangerous. 

Rovsing  has  had  a  special  apparatus  made:  (see  Fig.  iood)  "a  tube  of  india 
rubber  10  cm.  long,  which  at  one  end  is  provided  with  a  brass  ring  which  can 
be  screwed  on  to  the  ordinary  vaseline  tubes,  while  the  other  end  can  be  partly 
screwed  into  the  cannula  and  partly  into  a  close  fitting  cover,  which  fits  the 
cannula  and  during  the  boiling  can  be  closed  with  a  little  cover;  provided  with 
this  cover  the  rubber  tube  is  screwed  on  to  the  vaseline  tube  and  is  now  boiled 
together  with  this  for  fifteen  minutes  before  the  injection.  Then  the  joint 
is  punctured,  the  poincon  is  removed,  and  the  presence  of  synovia  in  the 
joint  ascertained.  In  such  a  case  catch  the  synovia  in  sterile  glass  tubes  for 
examination.  If  it  is  found  to  be  turbid  and  fluffy  the  injection  of  the  vaseline 
is  abandoned,  but  if  none  or  only  an  inferior  mass  of  clear  synovia  is  found, 
the  vaseline  tube  is  taken  direct  from  the  cooking  vessel  and  connected  with 

853 


854 


HIP. 


the  cannula  by  the  connection  tube,  which  after  the  cover  has  been  removed 
can  be  screwed  straight  on  to  the  cannula.  The  vaseline  is  now  driven  through 
the  tube  and  cannula  in  this  way:  the  vaseline  tube  is  rolled  up  from  the  bottom 
by  the  aid  of  a  tiny  little  handle  (Fig.  looi).     By  this  means  every  possibility  of 


Fig.  iooo. — (Rovsing,  Annals  of 
Surgery.) 


Fig.  iooi. — {Rovsing,  Annals  of  Surgery.) 


infection  of  the  vaseline  passing  from  the  tube  to  the  joint  is  precluded,  and  the 
method  is  in  every  respect  practical." 

Rovsing  when  injecting  insures  against  missing  the  hip-joint  by  exposing 
the  capsule  through  a  small  incision  just  above  the  trochanter. 

Arthrotomy. — There  are  several  routes  through  which  the  hip-joint  may 
be  opened. 


Fig.  I002. 

I.  Anterior  Arthrotomy. — Method  A. — Step  i. — From  a  point  about  i 
inch  below  and  a  finger's  breadth  internal  to  the  anterior  superior  iliac  spine 
make  an  incision  3  or  4  inches  in  length  downwards  along  the  inner  border  of 
the  sartorius  (Fig.  1002).  Expose  the  inner  border  of  that  muscle  and  retract 
it  outwards;  this  exposes  the  tendon  of  the  rectus  femoris  which  must  be  retracted 


ARTHROTOMY. 


855 


outwards,  exposing  the  ilio-psoas  muscle.     Retract  the  psoas  inwards.     The 
joint  capsule  is  now  exposed. 

Step  2. — Flex  and  abduct  the  thigh,  rotating  it  outwards.  This  permits 
more  free  access.  Incise  the  capsule.  Explore  the  joint.  If  drainage  is 
required,   provide  such  and  partly  close  the  wound. 

Method  B. — Step  i. — From  a  point  about  1/2  inch  below  and  external 
to  the  anterior  superior  iliac  spine  make  a  3-  or  4-inch  incision  downwards  and 
slightly  inwards.  The  upper  portion  of  the  cut  runs  along  the  outer  border 
of  the  sartorius,  lower  down  where  the  sartorius  and 
tensor  vaginas  femoris  separate,  the  cut  takes  a 
course  midway  between  these  muscles.  Retract  the 
sartorius  and  rectus  femoris  muscles  inwards.  The 
joint  capsule  is  now  exposed. 

Step.  2. — Same  as  in  Method  A. 

If  on  account  of  suppuration  it  seems  desirable 
to  provide  further  drainage  through  a  counter-open- 
ing, Labey  advises  the  following  procedure:  Abduct 
the  thigh  so  as  to  make  the  adductor  muscles  promi- 
nent. Locate  the  adductor  longus.  Make  a  4-inch 
incision  along  the  outer  border  of  this  muscle,  begin- 
ning about  one  finger's  breath  from  the  fold  of  the 
groin  and  a  little  external  to  the  root  of  the  scrotum. 
Divide  the  skin  and  subcutaneous  tissue.      Retract 

the  long  saphenous  vein  outwards;  ligate  and  divide  any  of  its  branches  which 
cross  the  wound.  Divide  the  deep  fascia  along  the  outer  border  of  the  adductor 
longus.  Push  the  finger  between  the  adductor  longus  and  the  pectineus 
which  lies  immediately  external  to  it.  The  thigh  being  now  flexed  as  well  as 
abducted,  hook  the  finger  under  the  pectineus.  Introduce  a  closed  forceps 
•  through  the  arthrotomy  wound,  make  the  forceps  traverse  the  joint  inwards 
and  downwards  so  as  to  make  the  inner  and  lower  part  of  the  capsule  promi- 
nent and  to  come  against  the  finger  pushed  into  the  secondary  wound  (Fig. 
1003).  Guided  by  the  finger,  make  an  incision  through  the  capsule  on  to  the 
forceps.  With  the  forceps  pull  a  large  drainage-tube  through  from  one  wound 
to  the  other. 

II.  Posterior  Arthrotomy. — ^Method  A,  Langenbeck's  Method. — • 
Place  the  patient  on  his  healthy  side  (latero-ventral  position).  Flex  the  thigh 
to  a  position  midway  between  extension  and  flexion  at  a  right  angle  to  the 
body  (45°). 

Step  I. — Beginning  at  a  point  about  two  fingers'  breadth  below  the  tip  of 
the  trochanter,  make  an  incision  along  the  mid-line  of  the  trochanter  in  the 
long  axis  of  the  femur,  upwards  for  about  4  to  4  1/2  inches  towards  the  posterior 
superior  iliac  spine  (Fig.  1004).  Divide  the  skin  and  subcutaneous  fat  so  as 
to  expose  the  gluteus  maximus  and  the  trochanter  which  is  covered  by  the 
strong  flat  tendon  of  the  gluteus  maximus. 


Fig.  1003.- — (Labey.) 


856 


HIP. 


Step  2. — Divide  the  tendon  on  the  trochanter  in  the  line  of  the  wound  and 
continue  this  division  upwards  so  as  to  penetrate  the  gluteus  maximus  by 
separating  its  fibres.  Retract  the  edges  of  the  muscular  wound  exposing  and 
then  dividing  the  layer  of  fat  covering  the  deeper  structures.  Expose  the 
pyriformis  (posterior  and  inferior)  and  the  gluteus  medius  (anterior  and 
superior).  Note  and  penetrate  the  groove  between  these  two  muscles.  Re- 
tract the  edges  of  this  deep  wound  so  as  to  expose  the  posterior  surface  of 
the  capsule. 

Step  3. — Incise  the  capsule  (Fig.  1005). 

Method  B.— Kocher's  Curved  Incision. — This  method  is  described 
in  the  chapter  on  arthrectomy. 

Arthrectomy.  Anterior  Incision. — Several  methods  have  been  devised 
for  approaching  the  joint  by  the  anterior  route  only  Barker's  plan  will  be 
described.     This  operation  is  enthusiastically  advocated  by  A.  E.  Barker. 

Step    I. — See  Anterior  Arthrotomy,  Method  B. 


Fig.   1004.. — {Esmarch  and  Kowalzig.) 


Fig.   1005. — -{Labey.) 


Step  2. — Open  the  joint  capsule  by  an  incision  parallel  to  the  neck  of  the 
femur.  Explore.  Do  not  dislocate  the  head  of  the  bone  through  the  incision. 
Divide  the  neck  of  the  femur  with  a  fine  saw  (Adams')  or  an  osteotome. 
Remove  the  head  of  the  bone.  Removal  of  the  normal  femoral  head  is  exceed- 
ingly difficult,  but  when  tuberculous  disease  is  so  advanced  that  excision  is 
necessary,  the  tissues  are  so  altered  and  softened  that  extraction  of  the  head 
is  usually  easy;  to  this  rule  there  are  some  striking  exceptions,  when  the  head 
of  the  femur  may  require  to  be  chiseled  from  the  cotyloid  cavity. 

Step  3. — With  the  irrigating  curette  scrape  away  all  soft  broken  down  tissues. 
With  long  forceps  and  scissors  dissect  away  all  evidently  diseased  synovialis, 
etc.  Examine  the  acetabulum  and  its  surroundings  and  if  found  diseased, 
remove  the  foci  with  the  curette,  chisel,  or  gouge.  Thoroughly  douche  the 
cavity  with  warm  water  tinged  to  a  dark  sherry  color  with  tincture  of  iodine. 

Step  4. — (a)  No  evidences  of  secondary  (pyogenic)  infection  is  present. 


ARTHRECTOMY. 


85- 


Fill  the  wound  with  iodoform-glycerine  or  iodoform  and  formalin  in  glycerine. 
Close  the  wound  without  drainage. 

(b)  Sinuses  are  present  or  there  is  evident  pyogenic  infection,.  Provide 
for  free  drainage.     Partly  close  the  wound. 

After-treatment. — Barker  writes  as  follows: 

"No  splint  is  required  immediately  after  the  operation,  the  limb  lying 
in  good  position,  as  a  rule,  if  left  to  itself,  no  muscles  having  been  divided. 
If  there  be  any  tendency  to  displacement  a  weight-extension  will  be  the  most 
suitable  means  of  correcting  it  in  the  first  instance.  As  the  wound  lies  in  front 
and  is  small,  there  is  no  difficulty  in  dress- 
ing it  without  moving  the  patient  in  the 
least,  hence  another  reason  for  discarding 
splints  at  first.  But  when  the  wound  is 
in  a  fair  way  to  heal,  the  author  is  in  the 
habit  of  putting  the  patient  upon  a  double 
Thomas'  splint,  in  which  he  can  be  re- 
moved from  bed  and  be  carried  out  for 
change  of  air  without  the  least  dis- 
turbance of  the  limb  or  of  the  dressing 
on  the  wound." 

External  or  Langenbeck  s  Incision. 
— Kbnig's  Method. — Place  the  patient 
on  his  sound  side  with  the  operating-table 
so  arranged  that  a  good  light  falls  on  the 
hip.  Three  assistants  are  necessary. 
One  stands  opposite  the  surgeon,  one  at 
the  patient's  back,  and  the  third  where  he 
can  manipulate  the  patient's  limb.  The 
surgeon  stands  behind  the  hip.  The 
thigh  is  in  a  position  of  semiflexion. 

Step  I. — Make  a  five  inch  incision  over  the  middle  of  the  trochanter  major 
in  line  with  the  long  axis  of  the  femur.  Rather  more  than  half  of  this  incision 
lies  above  the  trochanter,  between  it  and  the  posterior  superior  spine  of  the 
ilium  (Langenbeck's  incision,  Fig.  1003).  The  knife  is  made  to  penetrate  to 
the  bone  in  the  first  cut. 

Step  2. — With  long-bladed  retractors  separate  the  edges  of  the  wound, 
expose  the  capsule  and  divide  it.  Divide  the  periosteum  of  the  trochanter 
in  the  line  of  the  wound.  Do  not  separate  the  trochanteric  muscular 
insertions. 

Step  3. — With  a  broad  chisel  partially  cut  off  a  shell  of  bone  from  the  an- 
terior and  from  the  posterior  margins  of  the  trochanter.  Complete  the  separa- 
tion of  the  shells  of  bone  by  blunt  force,  leaving  them  loosely  attached  to  the 
shaft  of  the  femur,  the  periosteum  and  soft  structures  acting  as  a  hinge  (Fig. 
1006,  c,  c).     The  separated  portions  of  bone  bear  the  insertions  of  the  trochan- 


FiG.   1006. — (Kdnig.) 


858  HIP. 

teric  muscles.  The  remaining  portion  of  trochanter  (b)  must  be  removed 
flush  with  the  femoral  neck  by  means  of  the  chisel  or  bone  forceps. 

Step  4. — With  retractors  expose  the  femoral  neck.  Choose  the  point  at 
which  the  neck  is  to  be  divided.  With  a  periosteal  elevator  bare  the  bone  of 
the  neck  at  the  line  of  section.  Divide  the  bone.  For  this  purpose  use  a 
finger  saw,  or  better,  the  Gigli  wire  saw. 

Step    5. — -Removal    of    the   femoral   head. 

Konig  writes  as  follows:  "The  removal  of  the  head  is  often  difficult. 
Sometimes  it  has  sunk  into  the  cotyloid  cavity  which  has  been  widened  by 
disease  and  whose  inequalities  of  surface  have  hooked  themselves  on  to  similar 
inequalities  of  the  femoral  head;  sometimes  it  is  so  changed  in  form  that  it 
has  become  firmly  fixed  in  an  excavation  of  the  acetabulum;  occasionally 
its  surface  is  partially  or  entirely  united  to  the  bone  of  the  acetabulum.  In 
other  cases,  especially  when  acute  osteomyelitis  has  been  present,  the  epiphysis 
is  separated  and  the  head  itself  is  anchylosed  to  the  acetabulum. 


Fig.  1007. 

"In  simple  cases  when  room  is  made  by  pulling  the  limb  downwards  one 
can  remove  the  head  with  a  periosteal  elevator.  In  difficult  cases  a  specially 
strong,  spoon-faced  lever  is  required."  (The  author  has  had  one  made  of 
the  following  dimensions,  14X3/4X1/4  inches  (Fig.  1007).  It  reminds  one 
of  a  burglar's  "jimmy,"  but  is  thoroughly  efficient.) 

"In  unusually  difficult  cases  one  may  chisel  away  a  portion  of  the  posterior 
superior  rim  of  the  acetabulum  (c.  Fig.  1006).  This  would  be  done  in  any 
event   after   the   removal   of   the  head." 

Examine  the  trochanter  and  the  remnant  of  the  neck.  If  disease  is  present 
in  these  structures  attack  it  with  chisel  and  sharp  spoon. 

Step  6. — Examine  the  cotyloid  cavity  both  by  touch  and  sight.  Remove 
sufficient  of  the  posterior  superior  cotyloid  rim  to  permit  of  free  inspection  of 
the  cavity.  If  disease  exists  in  the  pelvic  bones  rem:)ve  it  thoroughly  with 
chisel  and  spoon.  In  cases  where  the  disease  has  invaded  the  pelvis  and  caused 
iliac  abscess,  the  latter  must  be  independently  opened  anteriorly  above  Pou- 
part's  ligament,  its  contents  evacuated,  its  cavity  cleaned,  filled  with  iodoform- 
formalin  glycerine  and  sutured. 

Step  7. — Excision  of  the  Synovialis. — Separate  the  synoviali?  from  the 
rim  of  the  acetabulum  and  from  its  inferior  insertions,  and  dissect  it  out. 
Long  stout  dissecting  forceps  and  scissors  curved  on  the  flat  are  convenient 
for  this  purpose.  Changes  in  the  position  of  the  limb  assist  in  giving  free 
exposure.  All  the  synovialis  may  be  excised  as  above,  except  sometimes  a 
pouch  which  runs  down  to  the  lesser  trochanter  and  must  be  thoroughly 


ARTHRECTOMY. 


859 


curetted.  The  sharp  spoon  so  often  recommended  for  the  removal  of  the 
synovialis   is  practically  useless  for  the  purpose. 

Step  8. — Irrigate  the  wound  with  hot  water.  The  addition  to  the  water 
of  sufficient  tincture  of  iodine  to  make  it  a  sherry  color  is  valuable.  Dry  the 
wound  with  sterile  gauze.  Introduce  a  cannula  or  tube  into  the  wound.  Close 
the  wound  with  deep  and  superficial  sutures.  Place  one  or  more  sutures 
(not  tied)  in  such  position  that  when  the  tube  is  removed  they  may  be  tied 
and  effectually  close  the  wound.  Through  the  tube  fill  the  wound  cavity 
with  iodoform-glycerine  or  iodoform-formalin-glycerine  or  Beck's  bismuth 
vaseline.     Remove  the  tube.     Fasten  the  last  sutures.     Apply  ample  dressings. 

James  E.  Moore  recommends  filling  the  wound  cavity  with  Mosetig's 
bone  plug.     Mosetig  himself  originally  only  used  this  plug  to  fill  cavities  actu- 


FiG.   1008. — {Huntington.) 


ally  cut  in  the  bone  itself.  His  plan  in  articular  caries  was  to  cut  (not  scrape) 
away  the  focus,  thoroughly  drj'  the  bone  cavity  left,  fill  the  cavity  with  the 
iodoform  wax,  cover  the  plug  with  rubber  tissue  and  gauze  until  the  rest  of 
the  operation  was  completed,  then  he  removed  the  rubber  tissue  and  gauze 
and  closed  the  wound  after  introducing  short  drainage-tubes.  Moore  in  one 
case  could  not  obtain  sufficiently  perfect  hemostasis  to  permit  the  use  of  the 
"bone  plug,"  hence  he  packed  the  wound  with  gauze  for  some  days  and  intro- 
duced the  plug  secondarily  with  good  results. 

If  secondary  infection  is  a  feature  of  the  case  and  especially  if  sinuses 


86o 


HIP 


exist,  then  the  above  treatment  is  improper;  the  sinuses  must  be  cleaned  by 
the  sharp  spoon,  rubbing  with  gauze  or  by  dissection.  Filling  the  cavity  and 
sinuses  with  Beck's  bismuth  paste  seems  to  be  efficacious. 

After-treatment.— Put  the  patient  in  bed.  Apply  extension  by  means 
of  weight  and  pulley  in  a  position  of  slight  abduction.  Keep  up  for  from  six 
to  eight  weeks  or  longer.  Use  nocturnal  extension  for  a  period  of  one  or  two 
years. 

Within  three  weeks,  if  all  goes  well,  begin  gentle  passive  motion.  After 
the  wound  is  satisfactorily  healed  massage  combined  with  passive  movements 
is  indicated,  and  active  movements  may  be  begun.  After  the  lapse  of  eight 
weeks  the  patient  may  be  encouraged  to  walk  with  crutches.     Huntington 

believes  that  in  most  cases  of  hip-joint 
disease,  whether  tuberculous  or  of  acute 
infective  origin,  the  primary  focus  is  situated 
in  the  neck  or  the  head  of  the  femur. 
Guided  by  X-ray  findings,  he  therefore 
trephines  on  the  outer  surface  of  the 
trochanter  major  near  its  base  and  through 
the  trephine  opening  tunnels  the  neck  of  the 
femur  until  he  reaches  the  disease  (Fig. 
1008).  If  sufficient  disease  to  account  for 
the  symptoms  is  found  before  the  epiphyseal 
cartUage  is  reached,  do  not  penetrate  that  . 
structure;  if  sufficient  disease  is  not  found 
in  the  neck,  then  the  epiphyseal  cartilage 
must  be  penetrated  and  the  head  entered. 
The  time  when  this  operation  may  promise 
most  is  the  time  when  non-operative  treat- 
ment is  usually  considered  indicated,  viz., 
early.  The  treatment  is  the  same  as  was  ad- 
vocated by  Macnamara  (Huntington,  "Surg.,  Gyn.,  and  Obstet."  ii,  p.  406). 

Angular  Incision.  Kocher's  Operation. — This  incision  may  be  used 
for  arthrotomy  as  well  as  for  arthrectomy.  Place  the  patient  on  his  sound 
side  in  the  latero-ventral  posture.  Slightly  flex  the  hip.  Let  an  assistant 
grasp  the  leg  so  as  to  change  the  position  of  the  thigh  according  to 
directions. 

Step  I. — Beginning  at  the  posterior  margin  of  the  base  of  the  trochanter 
major,  make  a  cut  upwards  to  the  posterior  angle  of  the  summit  of  the  tro- 
chanter (Fig.  1009) ;  at  this  point  change  the  direction  of  the  incision  and  cut 
upwards  and  backwards  towards  the  posterior  superior  iliac  spine,  i.  e.,  cut 
parallel  to  the  fibres  of  the  gluteus  maximus  and  expose  that  muscle.  Split 
the  tendon  of  the  gluteus  maximus  in  the  direction  of  its  fibres,  and  enlarge 
the  deep  wound  upwards  and  backwards  by  splitting  the  muscle  itself  in  a 
space  between  its  fibres  (Fig.  loio). 


Fig. 


1009. 


ARTHRECTOMY. 


86l 


Retract  the  edges  of  the  deep  wound,  exposing  the  gluteus  medius  at  its 
insertion  into  the  trochanter. 

Step  2. — Rotate  the  hip  slightly  inwards  so  as  to  make  prominent  the  poste- 
rior angle  of  the  summit  of  the  trochanter.  Find  the  groove  between  the  gluteus 
medius  and  minimus  above  and  the  pyriformis  below.  Beginning  at  this 
point,  separate  with  elevator  or  knife  the  insertions  of  the  gluteus  medius 
and  minimus  along  with  the  corresponding  periosteum  from  the  trochanter 
until  the  intertrochanteric  line  is  reached  anteriorly.  At  this  point  separate 
the  insertion  of  the  ilio-femoral  ligament.  WTiile  doing  this  flex  the  thigh  and 
rotate  it  outwards. 


Fig.   ioio. — (Kocher.) 


Step  3. — Divide  the  articular  capsule  along  the  lower  edge  of  the  pyriformis 
tendon;  flex  the  thigh  and  rotate  it  inwards  so  as  to  gai)i  acess  to  and  divide 
the  insertion  of  the  pyriformis.  With  elevator  or  chisel  (removing  a  thin  shell 
of  bone  if  desired)  separate  the  insertions  of  the  obturators  and  gemelli. 

The  rest  of  the  operation   requires  no  special  description. 

Larghi's  High  Curved  Incision. — A.  Von  Bergmann  ("Archiv.  fur 
klin.  Chir.,"  Ixix,  592)  strongly  recommends  the  above  incision  in  cases  where 
there  is  considerable  involvement  of  the  pelvic  bones.  The  cut  skirts  the 
iliac  crest  and  permits  reflection  downwards  of  the  gluteal  muscle.  The 
operation  was  originally  devised  for  excision  of  the  ilium,  but  it  has  been  used 
in  tuberculous  coxitis  and  e.specially  in  dislocation  of  the  hip  {q.  v.). 


862 


HIP. 


OUier's  Snuff-box  Method. — Place  the  patient  on  his  sound  side.    Flex 

the  thigh  to  an  angle  of  45°  and  adduct  so  as  to  make  the  trochanter  prominent. 

Step  I. — Make  the  semilunar   incision,  A,  B,  C   (Fig.   loii),  the  lowest 

point  (B)  being  about  2  inches  below  the  tip  of  the  trochanter,  the  points  A 

and  B  being  about  the  same  distance  in  front  of  and  behind  the  posterior 

and  anterior  edges  of  the  trochanter,  respectively. 
Divide  the  skin  and  deep  fascia. 

Step  2. — By  means  of  a  curved  incision  cor- 
responding exactly  to  the  skin  incision,  expose  the 
base  of  the  great  trochanter.  Continue  this  incision 
forwards  in  a  curve  so  as  to  penetrate  between  the 
anterior  fibres  of  the  gluteus  medius  or  between  the 
gluteus  medius  and  the  tensor  vaginae  femoris.  Con- 
tinue the  incision  backwards  in  a  curve  so  as  to  pene- 
trate between  the  fibres  of  the  gluteus  maximus. 

Step  3.— Method  A. — Pass  a  Gigli  wire  saw  round 
the  trochanter  major  and  cut  through  the  base  of  the 
trochanter  from  within  outwards  and  downwards. 
Method  B, — With  a  saw  cut  through  the  base  of  the  trochanter  from 
without  inwards  and  upwards  (Fig.  1012). 

Method   C. — Make   the   same   division   with   an   osteotome.     Whichever 
method  is  used,  divide  the  bone  obliquely  so  as  to  insure  easy  union. 

Step  4. — Reflect  upwards  the  separated  trochanter  with  its  muscles.     This 
exposes    the    joint    thoroughly    (Fig.    1013). 


Fig.   ioii. — (Labey.) 


Fig.   1012.- — (Labey.) 


Fig.   1013. — (Labey.) 


Step    5. — Treat   the   disease   as   already   described. 

Step  6. — If  the  trochanter  is  diseased,  remove  the  disease  or  the  trochanter 
itself,  as  may  be  indicated.  If  the  trochanter  is  healthy,  return  it  to  its  normal 
position  and  fix  it  there  by  sutures  (wire,  chromicized  catgut),  pegs,  or  screws. 
Provide  drainage  if  necessary.     Close  the  wounds.     Some  surgeons  fill  the 


ARTHRECTOMY.  863 

joint  cavity  with  iodoform  emulsion,  Mosetig's  plug  or  iodoform  starch  and 
close  without  drainage. 

Rutherford  Morison  operates  as  follows:  Make  a  convex  incision  immedi- 
ately above  the  trochanter  major.  Divide  all  the  muscles  inserted  into  the 
trochanter.  Dislocate  the  head  of  the  femur  through  the  wound.  Remove 
all  the  capsule,  synovial  membrane,  and  cartilage  from  the  head  and  the  ace- 
tabulum. Close  the  wound  completely.  Immobilize.  Do  not  remove  the 
head  of  the  femur  unless  it  has  become  a  sequestrum. 

Remarks. — When  coxitis  results  from  osteo-myelitis  the  treatment  ought 
to  be  by  excision.  While  arthrotomy  has  given  good  results,  yet  excision 
leads  to  a  quicker  recovery  and  so  avoids  the  more  remote  dangers  of  long- 
lasting  suppuration  (Hoffa).  When  there  is  hydrops  or  pyarthros,  puncture 
and  injection  with  some  fluid  such  as  formalin-glycerine  is  advisable  unless 
there  is  too  much  absorption  of  toxins,  in  which  case  arthrotomy  or  arthrec- 
tomy  is  indicated.  The  hydrops  of  typhoidal  coxitis  demands  puncture. 
In  tuberculous  coxitis  when  fistulae  are  absent  and  there  is  no  dislocation, 
conservative  measures  ought  to  be  thoroughly  tried,  especially  in  the  young. 
When  sequestra  are  demonstrated  they  must  be  removed  by  operation  after 
the  failure  of  conservative  measures. 

The  presence  of  fistulae  is  not  per  se  an  indication  for  radical  measures, 
conservative  means  (suction  hypera:;mia,  Beck's  paste,  etc.)  may  be  tried  if 
the  symptoms  are  not  pressing,  but  the  attempts  at  conservatism  must  not  be 
persisted  in  if  improvement  does  not  soon  show  itself.  Even  in  the  presence 
of  well-marked  visceral  tuberculosis  or  of  amyloid  disease  it  is  almost  always 
proper  to  prefer  excision  to  amputation  in  severe  cases  of  tuberculous  coxitis. 

Of  the  various  methods  for  excising  the  hip  the  author  prefers  that  of  Konig. 


CHAPTER  LXXIX. 
HIP.     ARTHRITIS  DEFORMANS. 

In  cases  of  arthritis  deformans  of  the  hip  in  which  there  is  much  disability 
from  pain,  muscular  spasm,  and  deformity,  F.  H.  Albee  ("Jour.  A.  M.  A.," 
June  13,  1908)  operates  as  follows: 

Step  I. — From  a  point  just  below  and  internal  to  the  anterior  superior 
iliac  spine  make  a  5-inch  cut  through  the  skin  and  subcutaneous  tissue  along 
the   inner    border   of    the    sartorius. 

Step  2. — Divide  the  deep  fascia.  Retract  the  sartorius  outwards.  Penetrate 
the  deep  structures  by  blunt  dissection.  Retract  the  iliacus  and  rectus  femoris 
inwards.     Expose  the  hip-joint. 

Step  3. — A  large  ring  of  osteophytes  generally  will  be  found  about  the  rim 
of  the  acetabulum.  Turn  such  upwards  with  the  soft  parts  adherent  to  them. 
This  is  easily  done  with   chisel   and   elevator. 


Fig.  1014.  Fig.  1015. 

Step  4. — Do  not  attempt  to  disarticulate  the  hip,  but  with  the  head  of  the 
femur  remaining  in  situ,  cut  away  about  half  its  upper  hemisphere  with  a 
large  chisel  in  a  plane  nearly  parallel  to  the  axis  of  the  femoral  neck  (Fig. 
1014).  In  the  same  manner  flatten  the  upper  part  of  the  aetabulum  so  that 
a  flat  surface  of  femur  lies  against  a  flat  surface  of  acetabulum,  when  the 
limb  is  abducted.     Remove  the  chips  of  bone. 

Step  5. — Abduct  the  limb  and  obtain  approximation  of  the  surfaces  of 
bone  made  flat  by  the  chisel  (Fig.  1015).  The  position  desired  is  one  of  slight 
overcorrection  with  abduction  to  overcome  the  shortening  which  is  always 
present.  Before  obtaining  the  desired  position  open  tenotomy  of  the  adductors 
at   their   origins   may   be   necessary. 

Step  6. — Suture  the  capsule  and  soft  parts.  Apply  dressings.  Immobilize 
in  a  position  of  abduction. 

Albee  has  used  this  operation  in  five  cases  with  gratifying  results. 

864 


CHAPTER  LXXX. 
OSTEOTOMY  HIP. 

Malpositions  with  bony  anchylosis  of  the  hip  and  certain  osseous  deformities, 
such  as  coxa  vara,  are  the  principal  lesions  which  necessitate  osteotomy  at 
the  hip.  Bony  anchylosis  may  be  due  to  one  of  several  causes — e.  g.,  tuber- 
culous osteo-arthritis,  fracture  of  the  femur  or  acetabulum,  etc.  \Vhen  choosing 
a  method  of  operating,  the  nature  of  the  lesion  causing  the  deformity  must  be 
taken  into  consideration.  An  operation  which  would  be  safe  in  a  case  of 
anchylosis  due  to  trauma  might,  in  one  due  to  tuberculosis,  relight  the  disease 
process  and  even  cause  its  dissemination.  The  choice  of  operation  must  also 
depend  on  whether  the  result  desired  is  a  joint  immobilized  in  good  position 
or  one  capable  of  movement. 

I.  Supra-Trochanteric  Osteotomy. — (A)  Subcutaneous  with  Saw. 
Adams'  Operation  (see  p.  838). 

(B)  Division  of  the  Femoral  Neck  with  Chisel  through  a  Small  Inci- 
sion.— Place  the  patient  on  his  sound  side.  At  a  point  immediately  above  the 
great  trochanter  make  a  vertical  incision  about  i  inch  long  down  to  the  neck 
of  the  femur.  Introduce  an  osteotme  alongside  the  knife  and  remove  the 
latter.  Turn  the  edge  of  the  osteotome  transversely  to  the  neck  of  the  femur 
and  divide  it  completely.  Do  not,  as  in  the  operations  for  genu  valgum,  etc., 
partly  divide  and  partly  fracture  the  bone;  this  might  result  in  dangerous 
splintering.  Apply  dressings.  Immobilize  the  limb  in  good  position  by 
means  of  extension,  splints,  plaster  of  Paris,  or  by  a  combination  of  these 
means.     Treat   the   case   as   a   fracture. 

Note. — Division  of  the  neck  of  the  femur  is  suitable  in  cases  of  bony  anchylo- 
sis where  flexion  is  the  only  deformity  present.  Of  course  when  the  head 
and  neck  are  profoundly  altered,  e.  g.,  in  bad  cases  of  coxa  vara  or  of  destructive 
osteitis  the  operation  is  often  impossible. 

(C)  Open  operation  with  introduction  of  muscle  between  the  cut 
surfaces  of  the  bone  (Nelaton's  operation)  (Huguier,  Traitement  des 
Ankyloses).     Arthroplasty. 

Step  I. — ^From  a  point  one  or  two  fingers'  breadth  below  the  anterior  superior 
iliac  spine  make  an  incision  through  the  skin  and  subcutaneous  tissue,  along 
the  anterior  border  of  the  trochanter  major.  This  incision  is  about  6  inches 
long.  Divide  the  fascia  throughout  the  length  of  the  wound.  Find  the 
inter-space  between  the  tensor  vaginae  femoris  and  the  sartorius;  separate  and 
retract  these  muscles  outwards  and  inwards,  thus  exposing  the  rectus  femoris 
and  more  deeply  the  ilio-psoas  (Fig.  10 16).  Strongly  retract  inwards  these  two 
55  865 


866 


OSTEOTOMY  HIP. 


muscles.  With  the  finger  palpate  the  great  trochanter  and  the  anterior  surface 
of  the  articular  capsule;  expose  this  latter  completely.  Split  the  capsule  from 
the  anterior  inferior  iliac  spine  to  the  trochanter,  preserving  the  ilio-femoral 
band  as  well  as  possible.  By  blunt  dissection  denude  the  anterior  surface  of 
the  neck  of  the  femur  and  expose  the  junction  of  the  head  of  the  femur  with 
the  cotyloid  cavity.     (These  structures  are  fused  together.) 

Step  2. — With  osteotome  and  mallet  divide  the  head  of  the  femur  where  it 
is  fused  to  the  pelvis.  Preserve  as  much  as  possible  of  the  head  of  the  bone 
attached  to  the  neck.     When  the  bone  is  divided,  clean  out  the  cotyloid  cavity 

with  gouge  and  rongeurs  so  as  to  make  it  con- 
cave and  smooth.  Smooth  and  round  off  the 
remnant  of  the  head  of  the  femur.  If  the 
trochanter  and  neck  of  the  femur  are  very  much 
deformed  and  are  so  anchylosed  to  the  ilium 
that  it  is  impossible  to  reform  the  head  and 
neck  of  the  bone,  divide  the  fused  mass;  cut 
a  cavity  in  the  iliac  bone ;  see  that  this  cavity  is 
provided  with  a  prominent  superior  and  poste- 
rior border;  round  ofif  the  top  of  the  upper  end 
of  the  femur  so  that  it  may  fit  into  the  above- 
mentioned  cavity. 

Step  3. — The  new  articulating  surfaces  hav- 
ing been  prepared,  interpose  a  layer  of  muscle 
between  them  as  follows:      Divide  the  rectus 
femoris  muscle  about  4  inches  below  its  origin, 
mobilize  it,   let  it  fall   into   the  new-formed 
cotyloid  cavity  and  fix   it  there  with  a  few 
sutures  (Fig.  1017). 
Step  4. — Place  the  femur  in  position.     Close  the  wound  with  or  without 
drainage.     Apply    dressings    and    extension.     Keep    immobilized    until    the 
wound  has  healed  and  then  gradually  begin  exercises. 

Rochet  has  shown  that  by  operating  from  the  front  the  glutei  muscles  and 
the  strong  upper  and  posterior  parts  of  the  capsule  are  preserved  intact.  These 
structures  prevent  the  femur  from  riding  up  over  the  ilium.  In  some  cases 
where  there  is  much  inversion  of  the  thigh,  the  anterior  operation  is  impossible 
and  it  becomes  necessary  to  adopt  Langenbeck's  or  Ollier's  incision  for  excision 
of  the  hip.  The  operation  so  far  as  exposing  the  joint  is  concerned  is  the  same 
as  in  excision  and  requires  no  special  notice  at  this  place.  The  bones  are 
divided  and  treated  as  in  Nelaton's  operation,  but  the  muscle  flap  used  for  inter- 
position is  obtained  from  one  of  the  glutei. 

Murphy's  Operation. — J.  B.  Murphy  ("Journ.  A.  M.  A., "May  20,  27; 
June  3,  1905),  reasoning  from  Langemak's  classical  researches  into  the  origin 
of  bursae  ("Archiv.  fur  klin.  Chir.,"  Ixx,  946)  and  from  some  experiments  of 
his  own,  concludes  that  fascia  and  fat  are  more  suitable  than  muscle  for  inter- 


ARTHROPLASTY. 


867 


Fig.  1017. — {Huguier.) 
a,  Flap  of  rectus  muscle ;  b,  ilio.  femoral  band;  c,  tensor  fascias  latse;  d,  sartorius;  e,  neck  of  femur. 


Fig.  1018. — {Murphy.) 


Fig.  1019. — {Murphy.) 


868 


OSTEOTOMY  HIP. 


position  between  the  ends  of  the  bone  after  section.  In  the  case  of  a  school 
boy  Murphy  operated  as  follows  and  obtained  a  brilliant  result: 

Step  I. — Make  a  V-shaped  incision,  with  the  trochanter  in  the  center  of 
the  V,  reaching  from  a  point  4  inches  above  to  a  point  2  inches  below  the  tro- 
chanter. The  open  end  of  the  V  is  5  inches  wide  and  directed  upwards.  Re- 
flect upwards  the  V-shaped  flap  containing  skin,  superficial  fascia,  and  fascia 
lata  (Figs.  10 18  and  1019). 

Step  2. — With  a  needle  and  guiding  suture,  pass  a  Gigli  wire  saw  round 
the  base  of  the  trochanter  major  and  divide  it  transversely.     This  may  be 


Fig.   1020. — {Murphy.) 


Turn   the   severed 
1020  and   102 1). 


trochanter   with   its   attached 


done   with   an   osteotome, 
muscles  upwards  (Figs. 

Step  3. — Incise  the  articular  capsule  and  separate  it  from  the  ilium  all  the 
way  round. 

Step  4. — Chisel  the  bony  material  (head  of  femur  and  new  bone)  filling  the 
acetabulum  from  the  latter,  beginning  at  their  line  of  junction  and  so  cutting 
that  as  much  as  possible  of  the  femoral  head  is  retained  (Fig,  1022).  After 
cutting  most  of  the  line  of  union,  the  remainder  may  be  fractured  by  moving 
the  thigh. 


ARTHROPLASTY. 


869 


Step  5. — With  chisel,  rongeurs,  and  scoop,  smooth  and  deepen  the  cotyloid 
cavity.     Similarly  round  off  and  smooth  the  head  of  the  femur. 

Step  6. — Dissect  the  fascia  lata  from  the  rest  of  the  original  V-flap  leaving 
its  base  intact.  With  this  fascial  flap,  line  the  new  cotyloid  cavity.  Fix  the 
new  lining  in  position  by  a  few  sutures.  Only  a  part  of  the  flap  and  that  near 
its  base  is  required  for  this  purpose,  the  apical  portion  will  be  used  to  cover 
the  femur.  By  manipulations  return  the  head  of  the  femur  into  the  socket 
(Fig.  102 1).  Suture  free  margin  or  apical  portion  of  the  fascial  flap  to  the  perios- 
teum and  capsule  attached  to  the  neck  of  the  femur.     The  is  important,  as 


Fig.   102 1. — {Murphy.) 


Murphy  considers  it  essential  that  every  part  of  the  new  articulating  surfaces 
be  covered  with  fascia. 

Step  7. — Peg  or  wire  the  divided  trochanter  major  in  its  old  position.  Close 
the  wound.     Dress  and  apply  extension. 

N.  B. — It  may  be  necessary  to  perform  tenotomy  on  one  or  several  muscles 
and  so  overcome  their  contraction  before  a  good  position  is  obtained.  (Figs. 
1018,  1019  and  1023  show  the  result  in  a  case  of  Murphy's.) 

II.  Trochanteric  Osteotomy. — Rhea  Barton  (Philadelphia)  was  the  first 
to  correct  deformity  in  hip  anchylosis  by  osteotomy.  His  line  of  section  was 
through  the  trochanter  major  (Fig.  1024) .     This  operation  is  not  performed  now. 


870  OSTEOTOMY  HIP. 

III.  Intertrochanteric  Osteotomy. — Sayre's  Operation. — Step  i. — 
Make  a  vertical  incision  from  a  point  just  above  the  tip  of  the  great  trochanter 
downwards  for  6  inches  along  the  mid-line  of  the  outer  surface  of  the  femur. 
From  the  middle  of  this  incision  make  a  transverse  cut  directly  backwards  for 
a  short  distance. 

Step  2. — Expose  the  anterior,  outer,  and  posterior  surfaces  of  the  upper 
end  of  the  femur  by  means  of  the  periosteal  elevator  until  the  trochanter 
minor  can  be  felt. 

Step  3. — Pass  a  chain  or  Gigli  wire  saw  around  the  femur  between  the  major 
and  minor  trochanters,  (a)  Make  a  A  or  fl-shaped  section  of  the  bone  (Fig 
1025).     Divide  the  upper  end  of  the  lower  fragment  transversely,  removing 

a  segment  of  bone  one-eighth  of  an  inch 
thick  at  its  outer  and  inner  margins.  With 
chisel  and  forceps  round  the  upper  end  of 
the  lower  fragment  so  as  to  lit  into  the  cavity 
in  the  upper  fragment. 

Step  4. — Close  the  wound  and  treat  as  a 
compound  fracture.  Sayre's  object  was  to 
obtain  a  mobile  joint,  but  one  can  hardly 
expect  much  success  from  the  original 
operation.  The  author  suggests  the  follow- 
ing modification  of  the  Sayre  method: 

Step  I. — Make  a  V-shaped  incision  hav- 
ing the  trochanter  midway  between  its  an- 
terior and  posterior  limbs,  reaching  from 
immediately  above  to  a  point  about  5  or  6  inches  below.  The  open  end  of 
the  V  incision  is  directed  upwards  and  the  distance  between  the  two  vertical 
portions  of  the  V  is  about  2  1/2  to  3  inches.  Reflect  upwards  the  V-shaped 
flap  which  must  consist  of  skin,  subcutaneous  tissue,  and  fascia  lata  (as  in 
Murphy's  operation). 

Step  2. — Pass  a  Gigli  wire  saw  around  the  femur  between  the  two  trochanters 

and  divide  the  bone  transversely  (the  division  may  be  made  with  an  osteotome). 

Step  3. — With  a  gouge  and  rongeurs  excavate  a  bowl-shaped  depression 

in  the  mass  of  fused  bone  (trochanter  major,  head  and  neck  of  femur  and  ilium) 

which  represents  the  anchylosed  hip. 

Step  4. — Separate  the  fascia  lata  from  the  reflected  V-shaped  flap,  leaving 
it  attached  by  its  base.     With  this  flap  line  the  new-made  cotyloid  cavity. 
Step  5. — With  rongeurs,  etc.,  round  off  the  upper  end  of  the  lower  fragment 
of  femur  and  fit  it  into  the  new  cotyloid  cavity. 

Step  6. — Close  the  wound.  Apply  dressings  and  extension.  When  the 
wound  is  healed  begin  motion. 

IV.  Subtrochanteric  Osteotomy. — Advantages  over  the  supra-or  inter- 
trochanteric operation:  (a)  Ease  in  performance,  (b)  Remoteness  from 
articulation  (important  in  tuberculous  disease),     (c)  Section  is  below  insertion 


OSTEOTOMY. 


871 


of  the  psoas  muscle.     If  this  muscle  could  act  on  the  lower  fragment  it  might 
cause  recurrence  of  the  mal-position. 

(A)  Transverse  Linear  Subtrochanteric  Osteotomy  (Gant's  Opera- 
tion).— Step  I. — At  a  point  four  fingers'  breadth  below  the  tip  of  the  great 
trochanter  over  the  external  surface  of  the  femur  make  a  vertical  incision 
down  to  the  bone.  The  incision  must  be  of  sufficient  length  to  permit  the 
easy  introduction  of  an  osteotome. 


Fig.  1023. — {Murphy.) 


Step  2. — Introduce  the  osteotome  with  its  cutting  edge  parallel  to  the  wound; 
when  the  osteotome  reaches  the  bone,  turn  it  so  that  its  cutting  edge  becomes 
transverse  to  the  long  axis  of  the  bone.  Cut  through  the  bone  as  in  supra- 
condyloid  osteotomy  (Fig.  1026). 

Step  3. — Remove  the  osteotome.  It  is  usually  unnecessary  to  insert  sutures. 
Place  the  limb  in  good  position.     Apply  dressings  and  extension. 

N.  B. — The  bone  section  may  be  made  with  an  Adams'  or  Jones'  saw 
instead  of  with  an  osteotome. 


872 


OSTEOTOMY  HIP. 


(B)  Oblique  Linear  Subtrochanteric  Osteotomy  (Terrier,  Mannequin). 
— Step  1. — Make  a  vertical  incision  5-6  inches  in  lengtli  along  the  middle 
of  the  outer  surface  of  the  femur  from  the  top  of  the  trochanter  major  down- 


FiG.  1024. 


Fig.  1025. 


1026 


wards.     Separate  the  periosteum  from  the  bone  over  its  anterior  and  external 
surfaces  corresponding  to  the  line  of  section  of  the  bone. 

Step  2. — With  an  osteotome  or  chisel,  cut  a  groove  across  the  outer  surface 
of  the  femur  immediately  below  the  great  trochanter.  This  groove  prevents 
slipping  of  the  osteotome  when  the  oblique  section  is  begun.     Using  this  groove 


1027. — {Hoffa. 


Fig.  io2&.~(Hofa.) 


as  a  starting-point,  divide  the  bone  obhquely  from  above  downwards  and  in- 
wards. The  antero-posterior  plane  of  section  ought  not  to  be  exactly  straight, 
but  ought  to  be  slightly  oblique  from  in  front  backwards  and  inwards.  This 
gives  better  apposition  of  the  fragments  when  extension  is  applied  (Figs.  1027 
and   1028). 


OSTEOTOMY. 


87: 


The  advantage  to  be  gained  from  the  obHquity  of  section  is  that,  when 
much  shortening  of  the  Umb  is  present,  extension  may  cause  the  divided  sur- 
faces to  slide  on  each  other,  and  thus  give  some  lengthening  while  the  fragments 
still  remain  in  apposition. 


Fig.   1029. — (Jones.)     Fig.   1030. — (Jones.) 


Fig.   1 03 1. — (Jones.) 


(C)  Linear  Oblique  Trochanteric  Osteotomy  (Berger's  Operation). — 
The  operation  is  almost  identical  with  the  preceding,  but  the  line  of  section  is 
as  shown  in  figures  1029,  1030.     The  technic  of  Berger's  operation  is  difficult. 


Fig.   1032. — -(Jones.) 

but  the  use  of  Jones'  saw  greatly  simplifies  it  as  the  hook  at  the  end  of  the 
blade  prevents  transfixion  of  the  tissues  and  also  prevents  the  saw  escaping 
from  its  groove  in  the  bone.     Robert  Jones  has  frequently  performed  this 


874 


OSTEOTOMY  HIP. 


operation  with  complete  success  in  cases  where  besides  flexion  there  was  much 
adduction  with  pelvic  tilting.  After  dividing  the  bone  he  cuts  the  adductors 
subcutaneously  and  in  the  case  of  a  youth  or  adult  applies  traction  by  means 
of  pulleys.  By  this  traction  an  inch  or  more  of  true  lengthening  may  often  be 
obtained  (Fig.  103 1).  After  applying  proper  dressings  he  places  the  leg  in  an 
abduction  splint  (Figs.  1032  and  1033),  which  is  arranged  so  as  to  keep  up  the 
extension.  The  degree  of  abduction  desired  depends  on  the  amount  of  short- 
ening and  of  pelvic  tilting,  i.  e.,  the  amount  of  true  shortening.  Fig.  1034  shows 
clearly  how  abduction  may,  by  tilting  of  the  pelvis,  give  apparent  lengthening 
to  a  truely  shortened  limb.  The  patient  must  1)e  kept  in  the  splint  for  seven  or 
eight  weeks  or  until   bony  union  is  complete.     Jones,   following  his  uncle, 


Fig.  1033. — {Jones.) 


H.  O.  Thomas,  and  Rushton  Parker,  does  not  fear  dividing  the  bone  through 
inflammed  tissue  when  this  is  necessary,  After  bony  union  is  secured  and  the 
splint  removed  the  limb  should  be  allowed  to  leave  the  abducted  position  slowly, 
and  exercise  should  be  prescribed  to  depress  the  pelvis  on  the  affected  side  and 
so  obtain  apparent  lengthening  of  the  short  limb. 

(D)  Cuneiform  Subtrochanteric  Osteotomy. — Step  i. — Make  a  2-  to 
3-inch  vertical  incision  over  the  external  surface  of  the  femur,  having  its  middle 
at  a  point  about  four  fingers'  breadth  below  the  tip  of  the  trochanter  major. 
Retract  the  edges  of  the  wound  and  reflect  the  periosteum  over  an  area  in- 
volving the  width  of  the  bone. 

Step  2. — With  chisel  and  mallet  excise  a  wedge  of  bone.  The  wedge  must 
of  course  be  so  placed  as  to  correct  the  deformity,  e.  g.,  if  there  is  a  deforming 


OSTEOTOMY. 


875 


degree  of  flexion  the  base  of  the  wedge  must  be  on  the  posterior  surface  of 
the  bone;  to  correct  adduction  the  base  of  the  wedge  must  be  external  (Fig.  1035). 
A  modification  of  cuneiform  is  trapezoidal  osteotomy  and  is  sufficiently  ex- 
plained by  Figs.  1036  and  1037. 

Step  3. — Straighten  the  bone.     Introduce  a  few  sutures.     Apply  dressings. 
Immobilize. 


Fig. 


[034. 


Fig.   1035. — {Berger  and  Bauzet.) 


Whitman  advises  cuneiform  osteotomy  at  the  level  of  the  lesser  trochanter 
in  young  children  with  coxa  vara.  He  writes:  "In  childhood  the  neck  of  the 
femur  is  short  and  the  strain  to  which  it  is  likely  to  be  subjected  slight,  thus 
operative  treatment  may  be  indicated  as  a  prophylactic  measure  while  in  ado- 
lescence operative  treatment  may  be  deferred  until  the  progression  of  the  de- 
formity has  ceased.  In  the  technic  of  this  procedure  there  are  several  points  of 
importance.     First,  all  restriction  of  abduction   of   ligamentous  or  muscular 


Fig.   1036. — {Berger  and  Bauzet.) 


Fig.  1037. — {Berger  and  Bauzet.) 


origin,  must  be  overcome  by  vigorous  manipulation  before  the  operation  on 
the  bone,  otherwise  it  will  be  difficult  to  bring  the  two  fragments  into  proper 
apposition.  The  base  of  the  wedge  should  be  about  three-quarters  of  an  inch 
in  breadth,  directly  opposite  the  trochanter  minor;  the  upper  section  should  be 
practically  at  a  right  angle  with  the  shaft,  the  lower  being  more  oblique  (Fig. 
1038).     The  cortical  substances  on  the  inner  aspect  of  the  bone  should  not  be 


876 


OSTEOTOMY  HIP. 


divided,  but,  reinforced  by  the  cartilaginous  trochanter  minor,  should  serve  as 
a  hinge  on  which  the  shaft  of  the  femur  is  gently  forced  outwards,  until  the 
opening  is  closed  by  the  apposition  of  the  fragments  after  the  upper  segment 
has  been  fixed  by  contact  with  the  margin  of  the  acetabulum  (Fig.  1038),  thus 
the  continuity  of  the  bone  is  preserved.  The  leg  is  then  held  in  the  attitude 
of  extreme  abduction,  by  means  of  a  plaster  spica  bandage,  which  should  in- 
clude the  foot  also,  until  the  union  is  firm. 

"The  opportunity  for  treatment  of  coxa  vara,  in  earliest  childhood,  is  rarely 
offered.     It  is  usually  the  direct  result  of   rachitis,  and  in  the  early  stage,  at 


Fig.   1038. —  {Whitman.) 


least,  it  is  probably  accompanied  by  other  rachitic  distortions.  It  would  be 
well,  therefore,  to  examine  the  hip-joints  of  rachitic  children,  especially  those 
who  present  the  deformity  of  genu  valgum  with  reference  to  this  distortion." 

Jones's  Operation?-. — In  bony  anchylosis  of  the  hip  following  tuberculosis 
or  sepsis  and  in  certain  forms  of  coxitis,  e.  g.,  malum  coxa  senilis,  where  the 
body  weight  acting  on  the  head  of  the  bone,  and  articular  friction  keep  the 
disease  active,  Robert  Jones  produces  a  pseudo-arthrosis  without  disarticulating 
the  head  of  the  femur.  The  operation  produces  much  less  shock  than  does  ex- 
cision of  the  head  of  the  bone  and  in  suitable  case  has  given  excellent  functional 
results. 

Step  I. — Make  a  6-inch  longitudinal  incision  along  the  outer  surface  of  the 
upper  end  of  the  femur.  One-half  of  the  incision  is  above  the  mid-point  of  the 
upper  border  of  the  trochanter  major  and  one-half  is  below.  This  cut  in  its 
lower  half  penetrates  to  the  periosteum  or  bone.     Retract  the  soft  parts. 


OSTEOTOMY. 


877 


Fig.  1039. —  {Jones.) 


Fig.   1040. — (Jones.) 


Fig.  1041. — (Janes.) 


Fig.  1042. — (Jones.) 


878 


OSTEOTOMY  HIP. 


Step  2. — Incise  the  periosteum  transversely  at  the  base  of  the  trochanter 
just  below  the  insertion  of  the  gluteal  muscles.  From  this  line  cut  through  the 
trochanter  to  its  junction  with  the  femoral  neck,  using  a  saw  or  a  wide  osteotome 
(Fig.  1039).     Retract  the  separated  trochanter  upwards. 

Step  3. — Open  the  joint.  Divide  the  neck  of  the  femur  near  the  head  of  the 
bone  with  an  osteotome  (Fig.  1039). 

Step  4. — Exert  strong  extension  on  the  femur.  Apply  the  cut  surface  of  the 
separated  trochanter  to  the  cut  surface  of  the  neck  of  the  femur  and  fix  it  there 


Fig.  1043. — {Jones.) 

with  a  screw  nail  (Fig.  1040) .     This  fixes  the  trochanter  to  the  head  of  the  femur 
which  is  still  in  the  acetabulum. 

Step  5. — Close  the  wound  with  deep  and  superficial  sutures.  When  there  is 
much  tenderness  it  may  be  necessary  to  remove  a  section  of  the  neck  instead  of 
merely  dividing  it,  so  as  to  avoid  "impinging."  ''In  the  case  of  an  anchylosed 
sound  joint  following  sepsis  it  may  be  advisable,  instead  of  dividing  the  neck 
near  the  acetabulum,  to  divide  it  near  the  trochanter  (Fig.  104 1)."  Where  there 
has  been  much  injury  due  to  disease  more  bone  may  be  removed  as  shown  in 
figures  1042  and  1043. 


CHAPTER  LXXXI. 

OLD  DISLOCATIONS  OF  THE  HIP. 

When  a  dislocation  of  the  hip  has  remained  unreduced  for  a  few  weeks  it  has 
become  practically  irreducible  by  manipulation  alone.  Even  recent  dislocations 
may  resist  manipulative  reduction.  The  principle  conditions  or  lesions  pre- 
venting reduction  are:  (a)  The  filling  of  the  cotyloid  cavity  with  fibrous  tissue 
which  often  becomes  osseous,  (b)  The  interposition  between  the  femur  and 
the  acetabulum  of  shreds  of  capsule,  fascia,  muscle,  etc.,  to  which  may  be  attached 
fragments  of  bone  torn  from  the  trochanter  or  broken  off  the  rim  of  the  acetab- 
ulum. 

(c)  Changes  in  the  shape  of  the  head  of  the  femur  due  to  its  adaptation 
to  new  surroundings,  also  fixation  of  the  femoral  head  in  a  new-formed  acetab- 
ulum. 

(d)  The  femoral  head  may  he  grasped  tightly  in  a  collar  formed  by  the  small 
external  rotator  muscles. 

(e)  The  "muscles,  ligaments,  and  fascia  surrounding  the  dislocated  bone 
adapt  themselves  to  their  new  conditions,  hence  they  are  contracted  or  shortened 
in  places  and  so  obstruct  reduction. 

(f)  Fracutres  of  the  head  of  the  bone  and  even  of  the  shaft  seriously  interfere 
with  reduction. 

I.  Posterior  Dislocations. — ^Method  A. — Step  i. — Make  a  5-inch  incision 
over  the  region  of  the  acetabulum  along  the  posterior  portion  of  the  trochanter 
major  (Fig.  1044).  Divide  the  tissues  attached  to  the  posterior  margin  of  the 
trochanter;  while  doing  this  hug  the  bone. 

Step  2. — Expose  and  clean  out  the  acetabulum.  If  necessary  for  reduction 
remove  the  parts  of  posterior  wall  of  the  acetabulum  with  chisel  or  rongeurs. 
This  assists  reduction  and  provides  for  drainage. 

Step  3. — Loosen  the  head  of  the  femur  from  its  surroundings  by  manipulation, 
by  blunt  dissection,  and,  if  necessary,  by  sharp  dissection. 

Step  4. — Reduce  the  dislocation  by  manipulation  of  the  limb  and  by  direct 
pressure,  etc.,  on  the  head  of  the  bone. 

Step  5. — ^Provide  for  drainage.  Close  the  wound.  Dress.  Apply  extension. 
While  operating  remember  that  the  great  sciatic  nerve  is  sometimes  picked  up 
by  the  dislocated  femur  and  passes  as  a  tight  band  over  the  neck  of  the  bone 
(Fig.  1045)  and  is  thus  in  distinct  danger. 

Method  B. — A.  von  Bergmann  ("  Archiv.  fur  klin.  Chir.,"  Ixix,  592)  advises 
the  use  of  Larghi's  incision  in  cases  of  the  old  hip  dislocation  whether  traumatic 
or  congenital  in  origin. 

879 


88o 


OLD    DISLOCATIONS    OF    THE   HIP. 


Step  I. — Make  an  incision  parallel  to,  and  immediately  below  the  crest  of  the 
ilium  from  the  posterior  inferior,  past  the  anterior  superior  spine  to  the  anterior 
inferior  spine  between  the  tensor  vaginae  femoris  and  sartorius  muscles.  This 
exposes  the  origin  of  the  gluteus  maximus  and  medius. 

Step  2. — Corresponding  to  the  skin  incision,  divide  the  gluteus  maximus, 
medius  and  minimus  close  to  their  origin,  but  preserve  the  periosteum  until  the 
top  of  the  sciatic  notch  is  reached ;  at  this  level  divide  the  periosteum  and  reflect 
it  also  downwards  along  with  the  overlying  soft  parts ( this  preserves  the  superior 
gluteal  artery  from  injury) .  Continue 
the  dissection  or  separation  down- 
wards subperiosteally  until  the  aceta- 
bulum is  well  exposed. 

Step    3. — After    exposure    of    the 
acetabulum,   separate  the   soft   parts 


Fig.   1044. — {After  Hoffa.) 


Fig.  1045.— (.4///5.) 


from  both  trochanters  by  division,  under  guidance  of  the  eye,  of  the  muscular 
insertions.  To  do  this  various  manipulations  of  the  thigh  are  necessary  so  as 
to  make  prominent  the  dislocated  head  of  the  femur. 

Step  4. — Examine  the  acetabulum.  If  necessary  prepare  it  for  the  reception 
of  the  head  of  the  femur.  By  manipulation  and  traction  reduce  the  dislocation. 
Various  tenotomies  may  be  necessary  to  permit  of  reduction. 

Step  5. — Close  the  wound  with  or  without  drainage.     Dress. 

Method  C. — Cheyne  and  Burghard  recommend  anterior  arthrotomy. 
M.  L.  Harris  uses  the  same  route.  In  one  case  Spencer  found  that  it  would 
have  been  impossible  to  reach  and  clear  the  acetabulum  through  a  posterior 
incision  without  resecting  the  head  of  the  femur. 


DISLOCATIONS.  88 1 

Step  I. — Make  a  4-inch  incision  downwards  and  forwards  from  just  beneath 
the  anterior  superior  spine  and  between  the  tensor  vaginae  femoris  and  the  sar- 
torius. 

Step  2. — Separate  the  above-mentioned  muslces  and  so  expose  the  region  of 
the  head  and  neck  of  the  femur.  "In  order  to  get  satisfactory  access  to  the 
acetabulum,  it  will  generally  be  found  necessary  to  detach  some  of  the  muscles 
from  the  ilium.  Division  of  the  tensor  vaginas  femoris  and  the  anterior  part  of 
the  gluteus  minimus  may  be  necessary,  as  they  will  probably  be  somewhat 
shortened." 

Slip  3. — Incise  the  joint  capsule  near  its  insertion  into  the  neck  of  the  femur. 
Divide  the  Y-ligament  and   obstructive   bands.     Clean  out  the  acetabulum. 

Step  4. — Reduce  the  dislocation.  It  may  be  necessary  to  divide  the  tendon 
of  the  obturator  internus  before  success  is  attained.  Close  the  wound  without 
drainage  if  hemostasis  is  complete  and  asepsis  assured;  if  necessary  posterior 
drainage  may  be  provided. 

After-treatment. — WTiatever  method  of  operating  is  chosen,  extension  by 
weight  and  pulley  should  be  applied.  At  an  early  date  begin  gentle  passive 
motion.  As  soon  as  the  wound  has  nearly  healed,  change  the  direction  of  the 
extension  from  day  to  day;  e.  g.,  at  first  the  extension  is  directly  in  the  line  of 
the  body,  change  it  so  that  the  hip  is  slightly  flexed,  then  make  the  extension  in 
such  a  manner  that  there  is  a  little  abduction,  and  so  on,  changing  the  position 
slightly  every  day.  Passive  movements  must  be  employed  daily,  unless  signs 
of  imflammation  are  present  in  the  wound.  At  as  early  a  period  as  possible 
after  healing  of  the  woimd  is  complete  active  movements  should  be  initiated. 
Too  much  importance  cannot  be  placed  on  thorough  after-treatment. 

II.  Anterior  Dislocation. — Perhaps  the  most  practical  way  to  describe  the 
operative  reduction  of  anterior  dislocations  will  be  to  give  a  resume  of  a  case 
operated  on  and  reported  by  Endlich  ("Archiv.  fiir  klin.  Chir.,"  Ivi,  585). 
Male,  thirty-seven  years  of  age.  Obturator  dislocation  of  three  months'  dura- 
tion. Incision  along  the  lower  (posterior)  edge  of  the  gracilis  from  the  symphy- 
sis pubis  downwards.  The  head  of  the  femur  was  reached  after  the  abductors 
were  penetrated.  The  femoral  head  lay  in  a  very  firm  capsule  of  fibrous  tissue 
containing  many  fragments  of  bone. 

Owing  to  the  depth  of  the  wound  and  density  of  tissues  the  bone  could  not 
be  freed  suflSciently.  The  patient  was  turned  on  his  right  side.  Langenbeck's 
incision,  six  inches  long,  was  made,  beginning  below  the  trochanter  major  and 
running  upwards  and  backwards  towards  the  posterior  superior  iliac  spine.  After 
penetration  of  the  gluteal  muscles  the  acetabulum  was  reached  and  found  filled 
-with  firm  fibrous  tissue  which  was  removed.  The  femoral  head  lying  in  front 
of  the  acetabulum  was  freed  from  the  adherent  soft  parts  by  blunt  and  sharp 
dissection.  Much  scar  tissue  containing  shell-like  fragments  of  bone  was  re- 
moved. After  removal  with  the  chisel  of  a  portion  of  the  anterior  edge  of  the 
cotyloid  cavity  opposite  the  femoral  head,  reduction  by  manipulation  was  success- 
ful. Both  wounds  were  loosely  packed  with  gauze.  Dressings  and  extension 
56 


882  OLD   DISLOCATIONS    OF   THE  HIP. 

applied.  The  result  was  at  first  disappointing,  but  poverty  forcing  the  patient 
(a  laborer)  to  work,  his  hard  labor  proved  the  best  after-treatment  and  the  out- 
come was  most  gratifying.  In  such  a  case  as  the  above  it  probably  would  be 
better  to  omit  the  first  (internal)  cut  made  by  Endlich  and  content  one's  self 
with  the  Langenbeck  incision. 

Dislocation  of  the  Hip  Complicated  by  Fractures. ^ — Fracture  of  the  shaft 
of  the  femur  complicating  dislocation  may  hinder  reduction  by  preventing  the 
use  of  the  bone  as  a  lever,  and  thus  compel  operation. 

When  there  is  extra-capsular  fracture  of  the  neck  of  the  femur,  expose  the 
bone,  if  possible  reduce  the  dislocation,  and  then  treat  the  fracture  secundem 
artem  (preferably  by  the  application  of  a  buried  metal  splint) .  If  reduction  of 
the  dislocation  is  impossible  or  improper,  the  separated  head  of  the  bone  may 
be  excised,  or  if  it  is  causing  no  pressure  symptoms  and  will  apparently  not  in- 
terfere vdth  the  ultimate  result  it  may  he  left  in  situ,  the  surgeon  aiming  to 
obtain  a  useful  pseudarthrosis. 

Intracapsular  fracture  comphcating  dislocation  usually  calls  for  excision 
of  the  head  of  the  bone. 

When  operative  reduction  is  impossible  or  seems  too  severe  a  tax  on  the 
patient,  excision  of  the  head  of  the  bone  may  be  indicated.  Osteotomy  may 
be  practised  instead  of  excision.  The  aim  of  this  operation  is  to  correct  dis- 
abling deformity  and  it  may  be  perfomed  in  such  a  fashion  as  to  provide  a  new 
joint  (see  Osteotomy).  Reduction  when  proper  is  of  course  the  operation  of 
choice.  Excision  is  preferable  to  osteotomy  when  the  displaced  bone  is  causing 
symptoms,  e.  g.,  pain  and  paralysis  from  pressure.  Osteotomy  may  be  pref- 
erable in  the  absence  of  the  above  troubles  and  when  it  is  doubtful  if  the  pa- 
tient's strength  is  equal  to  the  strain  involved  in  the  operation  of  excision,  and 
when  disabling  deformity  is  present  resulting  from  the  malposition.  Some- 
times the  malposition  may  be  corrected  to  a  practical  extent  by  non-operative 
treatment.  This  is  well  worth  trying.  When  the  dislocated  head  is  not  causing 
pressure  symptoms  and  when  after  exposure  reduction  is  impossible,  it  is  not 
always  necessary  to  excise  the  head  of  the  bone.  "The  best  thing  is  probably 
to  try  and  form  a  new  acetabulum  upon  the  iliac  bone,  in  the  new  position  that 
the  head  of  the  bone  occupies,  and  to  so  substitute  a  stable  and  movable  joint 
for  the  unstable  and  useless  one  resulting  from  the  dislocation.  To  do  this  a 
portion  of  the  pelvis  is  gouged  away  opposite  the  head  of  the  bone  until  a 
shallow  bed  is  formed  in  which  the  head  can  lie.  Instead  of  removing  the 
portions  of  bone  so  raised,  it  is  well  to  simply  gouge  them  upwards  and  then  bend 
them  at  right  angles  to  the  pelvis,  so  that  they  from  a  sort  of  buttress,  pre- 
venting the  head  of  the  bone  being  pulled  further  up.  In  the  course  of  a  few 
weeks  considerable  callus  is  thrown  out  around  the  portions  of  bone  detached 
in  this  way,  and  thus  an  obstacle  to  the  further  dislocation  of  the  head  is 
obtained"  (Cheyne  and  Burghard). 


CHAPTER    LXXXII. 
CONGENITAL  LUXATION  OF  THE  HIP. 

GwiLYM  G.  Davis. 

There  are  some  affections  which,  without  doing  special  harm,  the  practising 
physician  or  general  surgeon  can  deliberately  ignore  and  relegate  to  the  care 
of  the  specialist,  but  a  congenital  luxation  of  the  hip  is  not  one  of  them.  Although 
the  treatment  can  be  intrusted  to  the  specialist,  it  is  incumbent  on  those  who 
first  see  these  cases  to  recognize  their  serious  character,  and  this  in  too  many 
cases  they  fail  to  do.  The  affection  is  a  frequent  one;  its  manifestations  are 
obscure,  especially  in  its  early  stages;  untreated  it  never  undergoes  spontaneous 
cure,  but  progressively  gets  worse,  deforming  and  even  disabling  the  patient. 
Failure  to  recognize  the  affection  and  delay  in  instituting  treatment  increase 
the  difficulty  of  remedying  it  and  may  even  render  the  patient  a  permanent  and 
more  or  less  helpless  cripple.  For  these  reasons  the  general  physician  and 
surgeon  should  have  a  sufficient  knowledge  of  it  to  enable  him  to  suspect  and 
possibly  diagnose  its  presence  and  inform  the  parents  as  to  the  course  to  be 
pursued  in  having  it  properly  treated. 

Etiology. — The  cause  of  this  affection  is  unknown.  In  some  cases  the 
luxation  is  produced  at  the  time  of  birth,  but  few,  however,  can  be  accounted 
for  in  this  manner;  in  some  heredity  seems  to  play  a  part;  intra-uterine  disease 
has  also  been  held  to  be  a  factor,  but  this  has  not  been  generally  accepted. 
Retarded  development  does  not  account  for  it.  Perhaps  the  most  favorably 
received  theory  is  that  the  luxation  is  the  result  of  slowly  acting  force  exerted 
during  intra-uterine  life.  This  is  supposed  to  occur  in  cases  in  which  there  is  a 
lack  of  amniotic  fluid,  thus  allowing  the  uterine  walls  to  act  more  directly  and 
forcibly  on  the  extremities.  Codivilla  states  that  they  are  flexed,  adducted  and 
rotated  inwardly.  This  condition  existing  for  a  considerable  time  destroys 
the  stability  of  the  joint  and  favors  anatomical  changes;  the  capsule  becomes 
relaxed,  the  acetabulum  shallow  and  the  upper  end  of  the  femur  altered. 
The  preponderance  of  the  affection  in  females — six  or  seven  to  one — is  ex- 
plained by  the  sexual  anatomical  differences  in  the  pelvis,  which  begin  to 
manifest  themselves  as  early  as  the  fifth  month  of  intra-uterine  life. 

Prognosis. — Some  surgeons  appear  to  consider  congenital  luxation  of  the 
hip  as  not  a  very  serious  affection,  but  with  this  we  cannot  agree.  It  is  de- 
forming, painful,  disabling,  and  greatly  interferes  with  the  patient's  usefulness 
and  ability  to  earn  a  livelihood.  The  affection  is  least  marked  at  birth.  There 
is  no  pain  and  usually  it  is  only  when  the  child  begins  to  walk  that  the  trouble  is 
recognized.     The  gait  of  a  one-sided  luxation  is  a  marked  limp;  of  a  double, 

883 


884 


CONGENITAL   LUXATION    OF   THE  HIP. 


a  distinct  waddle.  Soon  the  back  becomes  hollow.  Perhaps  for  several  years 
the  patient  may  go  about  in  this  condition,  deformed  and  limping,  somewhat 
disabled  but  still  fairly  active.  As  age  advances  the  displacement  becomes 
more  marked.  Pain,  in  various  degrees,  is  experienced.  Difficulty  is  found  in 
going  up  and  down  stairs  and  walking  long  distances  is  impossible.  After 
puberty  a  rapid  increase  is  noted  and  if  compelled  to  earn  their  livelihood  these 
patients  try  to  obtain  a  sitting  occupation.  Even  then  they  are  sufferers, 
and  from  time  to  time,  at  least  temporarily,  are  compelled  to  rest  in  bed.  While 
there  may  be  intervals  when  they  are  free  from  pain,  still  they  are  liable  to  be 
disabled  at  any  time,  and  so  they  pass  a  more  or  less  miserable  existence.  If 
pain  is  at  all  constant  it  prevents  them  from  taking  a  sufficient  amount  of  exercise 
and  this  with  advancing  years  causes  them  to  take  on  fat  and  increase  in  weight 
which  all  tends  to  aggravate  their  distress,  and  their  condition  often  becomes 
pitiable. 


Fig.  1047. 

Anatomy. — The  bony  changes  are  marked.  The  acetabulum  (Fig.  1046) 
is  less  in  size  than  normal,  it  loses  its  round  form  and  becomes  narrowed  at 
the  sides,  thus  making  it  longer  vertically  than  in  its  horizontal  axis.  The 
cartilage  becomes  thicker,  thus  reducing  the  depth  of  the  acetabulum  and  the 
fat  and  fibrous  tissue  from  the  region  of  the  cotyloid  notch  encroach  upwards  and 
also  help  to  fill  it  up.  The  cartilaginous  rim,  especially  above  and  posterior, 
atrophies  and  this  together  with  the  filling  up  of  the  acetabulum  by  the  fatty 
and  fibrous  tissues  practically,  in  many  cases,  obliterates  the  concavity;  hence 
when  the  head  is  replaced  it  frequently  reluxates.  Sometimes  masses  of  carti- 
lage and  bone  are  found  in  the  acetabulum  in  operative  cases;  these  are  con- 
sidered by  Lorenz  to  be  out-growths  from  the  posterior  wall. 

The  acetabular  changes  are  frequently  found  at  birth,  though  they  increase 
with  age.     In  old  cases,  sometimes,  more  or  less  bony  out-growths  and  hollows 


DL\GNOSIS.  885 

exist  above  the  acetabulum,  which  tend  to  make  the  articulation  more  firm 
and  secure. 

The  femur,  also,  at  its  upper  extremity  (Fig.  1047),  while  somewhat  deformed 
at  birth,  is  still  more  deformed  as  age  advances.  The  head  is  smaller  than  nor- 
mal and  flattened  on  its  inner  posterior  portion.  In  some  cases  it  is  more  or  less 
pointed  while  in  others  it  is  markedly  flattened,  having  a  somewhat  mushroom- 
like shape.  The  neck  shortens,  and  its  angle  with  the  shaft  decreases  from  130° 
frequently  to  a  right  angle.  It  also  becomes  anteverted  from  the  10°  or  15° 
of  normal  to  almost  or  quite  90°.  In  extreme  cases  it  may  even  point  anteriorly 
instead  of  inwardly. 

The  pelvis,  while  at  birth  nearly  normal,  as  years  progress  becomes  distorted; 
it,  too,  is  atrophied.  The  true  pelvis  is  enlarged,  especially  in  its  transverse 
cUameter,  the  subpubic  angle  is  increased,  the  promontory  of  the  sacrum  more 
projecting,  and  the  tuber  ischii  wider  apart.  In  one-sided  luxations  the  asym- 
metry is  marked,  one  side  being  distorted  while  the  other  is  more  nearly  normal. 
The  pelvis  tilts  downwards,  lordosis  is  marked,  and  the  abandomen  protrudes. 
These  conditions  with  the  accompanying  distortions  sometimes  give  rise  to 
difficulties  in  parturition,  but  not  frequently. 

The  capsule  is  stretched  and,  being  compressed  between  the  head  and  side 
of  the  ilium,  it  may  fuse  or  become  united  with  the  periosteum  beneath.  The 
outer  side  of  the  capsule  is  stretched  across  the  acetabulum  and  in  rare  cases  is 
fused  vdth  the  fatty  fibrous  mass  occupying  it.  Between  the  orginal  acetabulum 
and  the  head  of  the  bone  the  capsule  may  be  contracted,  making  the  joint  cavity 
hour-glass  shape.  The  ligamentum  teres,  while  present  at  birth,  soon  atrophies. 
In  rare  instances  it  is  thickened,  but  usually  it  is  small  in  size  or  even  lacking. 
WTien  it  persists  it  is  found  as  along,  flat  ribbon-like  strand  (Fig.  1046).  Short- 
ening of  the  muscles  was  formerly  regarded  as  the  greatest  obstacle  to  reposition, 
and  the  cutting  operations  were  largely  founded  on  this  supposition.  The  head 
being  above  and  posterior  to  its  normal  position,  it  is  evident  that  the  muscles 
going  up  and  back  from  the  region  of  the  trochanters,  i.  e.,  the  glutei  will  be 
somewhat  shortened,  also  the  muscles  going  down  anteriorly  from  the  pelvis 
to  the  femur,  particularly  the  adductors;  but  this  shortening  is  of  little  practical 
moment,  because  it  is  readily  overcome  in  the  manipulations  used  in  reduction 
without  the  necessity  of  especially  rupturing  them,  as  does  Lorenz,  or  dividing 
them,  as  did  Broadhurst,  Hoffa,  and  others. 

Symptoms  and  Diagnosis. — The  history  is  that  of  a  congenital  affection, 
not  an  acquired  one,  and  an  abscene  of  traumatism.  This  aids  in  excluding 
hip  disease  and  coxa  vara.  A  marked  limp  appearing  when  the  child  begins 
to  walk  is  usually  the  first  thing  noticed  and  causes  physician  to  be  consulted. 
With  the  limp  is  associated  a  sinking  of  the  trunk  and  a  rolling  motion,  which  in 
bilateral  cases  produces  a  distinctly  waddling  gait.  It  is  peculiar  and  markedly 
different  from  that  due  to  coxalgia,  coxa  vara,  or  simple  shortening,  but  re- 
sembles more  that  of  paralysis.  It  is  usually  marked  from  the  time  the  child 
begins  to  walk  and  may  vary  in  degree  at  different  periods  of  life.     Pain  is 


886 


CONGENITAL   LUXATION    OF    THE  HIP. 


often  lacking  in  young  children  but  they  frequently  tire  readily,  and,  as  the 
patient  grows  older,  it  may  become  so  distressing  as  to  necessitate  confinement 
to  bed  for  considerable  periods  of  time.  The  affection  is  best  diagnosed  by  its 
physical  signs.  It  should  be  remembered  that  the  head  of  the  femur  is  above 
and  usually  behind  the  acetabulum.  This  tends  to  make  the  trochanter  of  the 
affected  side  prominent.  In  a  unilateral  luxation  this  may  be  somewhat  con- 
cealed by  an  inclination  of  the  trunk  towards  the  affected  side,  but  in  double 
luxations  (Fig.  1048)  it  is  sufficiently  marked  to  widen  the  space  considerably 
across  the  perineum  from  one  thigh  to  the  other.  In  unilateral  luxations 
(Fig.  1049)  the  tilting  of  the  trunk  towards  the  afifected  side  will  be  evident. 
There  is  no  turning  inwards  of  the  foot  such  as  is  present  in  traumatic  luxations. 


Fig.  104 


Fig.  1049. 


Fig.  1050. 


Viewed  from  the  side  there  will  be  seen  a  hollowness  of  the  back  (Fig.  1050), 
lordosis,  due  to  the  tilting  of  the  pelvis  forward  and  an  accompanying  promi- 
nence of  the  buttocks.  In  unilateral  cases  a  twisting  of  the  pelvis  may  be 
noticeable  and  in  order  to  compensate  for  the  shortening  of  the  affected  limb 
the  opposite  one  may  be  slightly  fliexed  both  at  the  hip  and  knee.  A  tendency 
to  flexion  of  these  joints  exists  also  in  the  affected  limb  and  particularly  so  in 
the  older  cases  of  double  luxation ;  when  the  patient  stands  upright  flexion  of 
both  hips  and  knees  may  be  marked.  This  is  due  to  the  tilting  of  the  pelvis 
forwards. 

Viewed  posteriorly  the  increased  breadth  across  the  pelvis  from  one  trochan- 
ter to  the  other  is  noticed  (Fig.  1048) ;  the  trochanters  are  prominent  and  the 
buttock  beneath  flattened.  In  unilateral  luxation  the  gluteo-femoral  fold  of  the 
affected  side  is  lower  than  that  of  the  sound  side,  and  the  trunk  is  also  inclined 
towards  the  affected  side.     Trendelenburg  has  pointed  out  that  if  the  child 


DIAGNOSIS. 


887 


stands  on  the  sound  leg  and  flexes  the  affected  one  the  lines  of  the  folds  of  the 
buttocks  will  remain  nearly  level  (Fig.  1051),  whereas  if  it  stands  on  the  affected 
limb  and  flexes  the  sound  one  the  gluteal  fold  on  the  sound  or  flexed  side  will 
drop.     This  is  due  to  the  increased  tilting  of  the  pelvis  in  the  latter  case. 

On  more  closely  examining  the  patient  it  will  be  found  that  by  acutal 
measurement  in  unilateral  cases  there  vdll  be  a  shortening  on  the  affected  side 


Fig.  1 05 1. 


Fig.  1052. 


which  is  considerable  and  in  old  cases  may  amount  to  one  and  a  half  to  two 

inches.     It  is  rendered  apparent  by  adopting  Allis's  procedure  of  having  the 

patient  flat  on  the  back  and  flexing  the  knees  and  hips  to  a  right  angle,  the  knee 

of  the  sound  side  will  be  seen  to  project  far  above  that  of  the  affected  side  (Fig. 

1052).     If  the  patient  is  seated  on  a  chair  in  front  of  the  examiner  one  knee  can 

be  both  seen  and  felt  to  be  considerably  in  advance  of  the  other.     To  determine 

the  location  of  the  shortening  it  is  necessary 

to  compare  a  bony  landmark  of  the  femur 

with  one  on  the  pelvis.     For  this  purpose 

the  upper  edge  of  the  greater  trochanter  and 

the  anterior  superior  spine  of  the  ilium  are 

used.     If  the  measured  distance  from  the 

tip  of  the  greater  trochanter  on  one  side  to 

the  corresponding  external  malleolus  is  the 

same  as  that  of  the  opposite  side  while  the 

distances  from  the  anterior  superior  spine 

to  the  internal  malleolus  on  the  two  sides 

differ  it  is  evident  that  the  cause  of  this 

difference   is   located   above   the   greater    trochanter  and  that  it  lies  higher 

than  normal.      This  may  be  due  to  either  dislocation,  fracture,  or  disease 

affecting  the  head  and  neck  of  the  bone.      Normally,   the  upper  edge  or 

tip    of   the    greater   trochanter   lies   almost    exactly  on   a  line  dravsm  from 

the  anterior  superior  spine  to  the  tuberosity  of  the  ischium — Nelaton's  line 

(Fig.    1053).      In  congenital  luxations,  the  upper  edge  of  the  trochanter  is 

considerably  above  it,  proportionate  to  the  amount  of  shortening.     Normally, 


Fig.  1053. 


CONGENITAL    LUXATION    OF    THE   HIP. 


the  upper  edge  of  the  trochanter  lies  obliquely  downwards  and  backwards 
from  the  anterior  superior  spine,  but  in  these  luxations  it  is  usually  opposite 
the  level  of  the  anterior  spine  and  sometimes  above  it.  What  may  be  called 
the  iliotrochanteric  angle  is  lessened  or  even  abolished.  The  position  of  the 
head  of  the  bone  should  be  identified.  Normally,  it  can  be  recognized  lying 
beneath  the  femoral  artery  just  below  Poupart's  ligament.  The  artery  crosses 
the  femoral  head  a  little  internal  to  its  middle  (Fig.  1054).  If  the  hip  is  grasped 
between  the  thumb  anteriorly  and  fingers  posteriorly,  the  thumb  being  just 
external  to  the  artery,  by  rotating  the  limb  the  head  can  be  felt  moving  under 
the  thumb.  In  luxations  the  head  is  displaced  posteriorly,  upwards  and  out- 
wards. So  deep  is  it  that  it  is  more  readily  recognized  by  the  fingers  which  are 
posterior  than  by  the  thumb  which  is  anterior;  this  is  especially  the  case  when 
the  limb  is  markedly  rotated  inwards.     The  range  of  motion  of  the  luxated 


Iliacus  Muscle. 

Pouparfs  Lig. 

PsomMiisde. 

Fe/jioml  A. 

Jl moral  V. 

'Ff?mral  C. 

'Fecfineus 

Mus. 


Fig.  1054. 


hip  is  increased  in  adduction  while  it  is  decreased  in  abduction.  The  lessened 
abduction  is  usually  not  so  marked  as  in  coxa  vara  (a  lessening  of  the  angle 
between  the  neck  and  shaft),  although  in  some  cases  a  condition  of  coxa  vara 
may  be  present  in  which  case  abduction  would  be  markedly  restricted.  Ad- 
duction may  be  so  much  increased  as  to  allow  the  thigh  of  the  affected  side  to 
be  brought  across  the  groin  of  the  opposite  one. 

The  looseness  of  the  joint  may  be  demonstrated  with  the  child  lying  on  the 
back,  having  its  limbs  either  extended  or  flexed.  If  the  limb  to  be  examined  is 
extended,  the  surgeon  grasps  the  two  sides  of  the  pelvis  with  his  hands  to  fix  it. 
On  the  suspected  side  the  thumb  is  placed  on  the  anterior  superior  spine  while 
the  index  finger  touches  the  top  of  the  greater  trochanter.  An  assistant  now 
grasps  the  leg  and  alternately  pulls  it  down  and  pushes  it  up.  If  the  hip  is 
luxated  the  greater  trochanter  will  be  felt  sliding  up  and  down. 


TREATMENT. 


889 


In  examining  the  limb  in  a  flexed  position  (Fig.  1055),  a  method  valuable  in 
children,  the  knee  is  grasped  with  one  hand  and  the  thigh  flexed  to  a  right  angle. 
The  thumb  of  the  other  hand  is  placed  in  front  of  the  anterior  spine  and  the 
Angers  beneath  the  trochanter.  On  pushing  and  pulling  the  femur  with  one 
hand  the  greater  trochanter  is  felt  with  the  other  to  slide  up  and  down  on  the 
side  of  the  pelvis.  Sometimes  in  examining  these  congenitally  luxated  hips  in 
this  manner  a  distinct  grating  or  cracking  can  be  felt. 

While  one  is  usually  able  to  diagnose  the  condition  by  the  physical  exami- 
nation, it  is  nevertheless  desirable  whenever  possible  to  have  a  skiagraph  made. 
This  will  enable  one  to  judge  with  exactness  the  height  of  the  head  in  relation 
to  the  acetabulum  and  to  a  less  extent  the  amount  of  anteversion  of  the  neck  and 
may  give  considerable  information  concerning  the  formation  of  both  the  head 
and  upper  end  of  the  femur  as  well  as  the  acetabulum.  It  will  not,  however, 
enable  one  to  detect  a  posterior  displacement.  Fortunately,  this  latter  is  almost 
always  associated  with  a  certain  degree  of  upward  displacement  which  can  be 
recognized  and  a  posterior  displacement  can  usully  be  detected  by  a  careful 
physical  examination. 


Fig.  1055. 

Treatment. — In  1826  Dupuytren  stated  that  cure  of  congenital  luxation 
of  the  hip  was  impossible,  but  advised  a  pelvic  girdle  as  a  palliative  measure. 
Later  Landerer  used  a  corset  to  counteract  the  lordosis  and  Langgaard  devised 
a  brace  which  was  fastened  about  the  pelvis,  passed  down  the  thigh  and  pos- 
sessed a  pad  which  made  screw  pressure  over  the  trochanter. 

Attempts  at  immediate  reposition  were  made  by  Humbert,  but  were  not 
successful,  and  the  subject  was  brought  into  prominence  by  C.  G.  Pravaz,  of 
Lyons,  in  1847.  Instead  of  the  rapid  traction  of  Humbert,  he  used  strong 
continuous  traction  for  four  to  eight  months  and  then  by  means  of  extension, 
abduction,  and  strong  pressure  by  a  large  roll  under  the  trochanter  replaced  the 
head.  Reluxations  he  treated  by  repeated  replacements.  His  results  were  not 
sufl&ciently  good  and  his  methods  were  abandoned,  only  to  be  revived  by  Buck- 
minster  Brown  of  New  York,  who  was  followed  by  Bradford  of  Boston,  Adams 
of  London,  and  others.  The  entension  treatment  was  brought  to  its  greatest 
perfection  by  Max  Schede  and  Mikulicz  in  1894,  both  of  whom  obtained  fairly 
good  results. 


890  CONGENITAL   LUXATION    OF   THE  HIP. 

The  operative  treatment  began  about  1840  with  Guerin  who  tenotomized 
the  muscles  attached  to  the  greater  trochanter.  He  was  followed  by  Brodhurst, 
Bouvier,  Barwell,  Pravaz,  Jr.,  Coolidge,  and  others.  Resection  of  the  head  by 
Rose  in  1874  and  Margary,  of  Italy,  in  1882  proved  after  a  full  trial  to  be  un- 
satisfactory. 

The  question  of  operative  treatment  was  finally  solved  by  Alfonzo  Poggi,  of 
Bologna,  who  in  1888  replaced  the  head  of  the  femur  in  a  newly-made  acetabu- 
lum by  open  incision.  He  was  followed  by  Hoff a,  who  in  1 890  and  subsequently, 
systematized  the  technic  and  caused  the  operation  to  be  generally  accepted.  In 
1892  Lorenz  advocated  an  incision  along  the  posterior  edge  of  the  tensor  fasciae 
femoris  muscle  instead  of  the  posterior  incision  of  Langenbeck  as  used  by  Hoffa. 
Hoffa  himself  later  adopted  a  straight  incision  along  the  anterior  edge  of  the 
greater  trochanter.  The  cutting  operation  reached  its  acme  in  1894  when  it 
was  advised  by  many  in  preference  to  all  other  measures. 

At  the  International  Congress  in  Rome  in  1894,  papers  were  read  by  Hoffa 
and  Lorenz  advocating  their  cutting  operations.  Kirmisson  and  Mikulicz  in- 
clined to  traction  treatment  and  Paci  gave  a  resume  of  the  work  which  he  had 
previously  published  in  the  "Archivio  di  ortopedia"  in  1890,  1891,  1892,  and 
1893.  He  stated  that  he  had  practised  his  bloodless  reposition  method  in  twenty- 
eight  cases,  twenty-three  of  congenital  luxation,  three  of  pathological,  and  two 
of  old  traumatic.  He  claimed  good  results  from  it  in  patients  from  three  to 
twenty-one  years  of  age.  He  presented  the  pelvis  of  a  child  of  seven  years  in 
whom  Nota,  of  Turin,  had  replaced  the  hips  four  months  previously.  In  one  of 
these  hips  there  was  practically  a  perfect  result.  He  also  demonstrated  his 
method  on  a  patient  before  the  assembled  members. 

The  effect  was  magical.  From  this  time  forth  the  bloodless  method  was 
taken  up  and  the  cutting  operation  reserved  for  exceptional  cases.  The  following 
year  Lorenz,  of  Vienna,  brought  out  his  modification  of  Paci's  method,  and  some 
changes  have  been  introduced  by  various  surgeons  since  that  date. 

Method  of  Paci. — ("Transactions  of  eleventh  International  Medical 
Congress,"  Rome,  1894,  p.  378.)  Paci,  as  he  himself  said,  used  the  ordinary 
circumduction  method  which  had  been  systematized  in  Italy  by  Fabbri.  It 
was  as  follows:  First,  Flex  the  thigh  well  on  the  abdomen,  then  push  forcibly 
down  on  the  'knee  so  as  to  force  the  head  downwards.  Second,  while 
retaining  the  limb  in  the  previous  position  slowly  abduct  the  knee  until  it  is  15 
cm.  (6  inches)  away  from  the  side  of  the  body.  Third,  rotate  externally 
until  the  axis  of  the  leg  (held  at  90°  to  the  thigh)  is  perpendicular  to  the 
long  axis  of  the  body.  Fourth,  gradually  extend  the  limb  while  being  held 
in  external  rotation. 

The  extension  was  carried  as  far  as  was  possible  without  the  head  reluxat- 
ing.  Sometimes  the  thigh  was  bent  over  the  edge  of  the  table  and  force  was 
used,  to  the  extent  in  one  case  of  breaking  the  femur.  The  limb  was  placed 
in  plaster  and  weight  extension  used  for  four  months  and  then  removed  and 
the  patient  kept  on  crutches  for  six  months  longer. 


LORENZ  S    OPERATION. 


891 


Lorenz  Technic. — (Joachimsthal,  "Handbuch  der  Orthopadischen  Chir- 
urgie,"  vol.  ii,  p.  169,  etc.)  The  thigh  is  abducted  until  the  adductor  muscles 
are  tense.  These  are  then  ruptured  by  direct  pressure  made  with  the  ulnar 
border  of  the  hand  by  cutting  or  sawing  movements.  In  difficult  cases  abduct- 
ing and  rotary  movements  are  made  to  mobilize  the  joint.     Also  traction  may 


Fig.  1056. 

be  made,  either  manual  by  the  surgeon  or  instrumental  or  by  two  assistants 
pulling  on  a  skein  of  yarn  looped  around  the  malleoli  or  the  condyles  of  the 
femur.  Counter-traction  is  made  by  fastening  a  sheet  to  the  table  while  the 
perineum  is  protected  by  a  pad  of  spongy  rubber. 

Reduction  (Fig.  1056)  is  to  be  accomplished  by  having  an  assistant  fix  the 
pelvis  by  pressure  on  the  opposite  side;  the  operator  then  grasps  the  hip  with 


Fig.  1057. 

one  hand,  the  thumb  being  posteriorly  on  the  trochanter,  and  the  flexed  knee 
with  the  other,  the  thigh  being  vertical.  The  trochanter  is  then  pushed 
upwards  and  forwards  with  one  hand,  while  the  thigh  is  lifted  (traction)  and 
abducted  with  the  other  until  it  is  at  right  angles  to  the  long  axis  of  the  body 
in  the  frontal  plane  or  even  a  little  more.     If  these  manoeuvres  do  not  suffice, 


892  CONGENITAL   LUXATION   OF   THE  HIP. 

a  wedge-shaped  block  (its  edge  covered  with  padding)  is  placed  beneath  the 
trochanter  and  the  abduction  is  made  over  this  (Fig.   1057). 

Hoffa  ("  Joachimsthal,"  vol.  ii,  p.  176)  abducted  to  90°  the  flexed  and 
strongly  externally  rotated  thigh.  It  was  moved  to  and  from  the  body,  up 
and  down  like  a  pump-handle  ("Pumpenschwengel")  until  it  reached  the 
horizontal. 

The  Bartlett  machine  ("Journal  of  Medical  Research,"  x,  440.,  1904), 
much  used  in  a  modified  form  in  Boston,  resembles  in  principle  that  of  Max 
Schede.  By  it  traction  is  made  with  a  winch  and  the  femur  forcibly  abducted 
to  90°.  The  limb  is  then  removed  from  the  apparatus  and  the  luxation  re- 
placed by  manipulation,  or  attempts  may  be  made  to  push  the  head  into 
place   while   traction   is   still    being   made. 

R.  H.  Hibbs  ("New  York  Medical  Jour.,"  Apr.  25,  1908)  fastens  the  patient 
to  a  table  by  two  straps  passing  over  the  crests  of  the  ilia  and  down  between 
the  thighs,  thus  fixing  the  pelvis  firmly.  Then  the  leg  is  extended  on  the 
thigh,  with  the  thigh  held  in  adduction  and  flexion  on  the  abdomen,  thus 
forcing  the  head  below  the  acetabulum.  A  metal  wedge-shaped  block  is 
then  brought  up  through  a  hole  in  the  table  and  adjusted,  by  a  ball-and- 
socket  joint,  against  the  trochanter  so  as  to  direct  the  head  upwards  and  for- 
wards. The  thigh  is  then  extended  and  abducted,  forcing  the  head  to  travel 
upwards,  anteriorly,  into  the  acetabulum.  He  has  used  the  method  in  fourteen 
hips  in  thirteen  children  from  twenty  months  to  eleven  years  of  age.  The 
limb  is  put  up  in  varying  degrees  of  flexion  and  abduction  and  he  "doubts  the 
necessity  of  any  case  wearing  plaster  more  than  two  months,  and  at  the  most 
three,  and  in  many  a  shorter  time."  In  only  one  case  was  there  reluxation 
requiring  a  replacement. 

Author's  Pressure  Method  (G.  G.  Davis,  "American  Journal  of  Ortho- 
pedic Surgery,"  Jan.,   1907): 

The  commonly  used  means  of  replacing  a  congenital  luxation  of  the  hip 
is  by  the  Paci-Lorenz  method.  This  is  essentially  a  lever  method,  the  fulcrum 
being  either  the  ilio-femoral  (Y)  ligament,  a  block,  the  hand  as  used  by  Lorenz, 
the  edge  of  the  table  as  used  by  Paci,  or  a  hard  roll  as  used  by  Pravaz.  The 
accidents  accompanying  this  method  have  been  numerous  and  are  a  constant 
menace.  To  avoid  them  and  yet  to  apply  the  requisite  amount  of  force  the 
writer  substitutes  direct  pressure  for  leverage.  It  is  applied  as  follows: 
The  child  is  placed  on  the  table  face  downwards  with  the  pelvis  resting  on  a 
sand-bag  and  the  leg  hanging  down  over  the  edge  of  the  table.  If  the  table 
is  well  padded  the  sand  pillow  may  be  dispensed  with.  The  thigh  is  then 
well  flexed,  and  brought  close  to  the  body  of  the  patient,  the  knee  being  flexed, 
and  held  there  either  by  the  operator  (Fig.  1058)  or  by  an  assistant  (Fig.  1059). 
The  operator  then  places  the  base  of  the  palms  of  his  hands  on  the  trochanter 
and  head  and  makes  downward  pressure  aided  by  the  weight  of  his  body.  By 
this  means  the  head  is  forced  from  its  posterior  to  an  anterior  position  and,  in 
easy  cases,  the  reduction  is  practically  complete,  sometimes  taking  place  with 


DA\^S  S    OPERATION. 


893 


the  usual  jump  or  click.  If  the  case  is  more  dithcult  and  more  abduction  is  re- 
quired, the  patient  may  be  brought  more  towards  the  middle  of  the  table  so  that 
the  knee  and  part  of  the  thigh  are  supported  by  its  edge  and  pressure  again  applied. 
Still  more  abduction  can  be  obtained  by  placing  a  pad  of  towels  beneath  the 
knee  so  as  to  elevate  it  still  more  (Fig.  1060).  By  this  means  hyperabduction 
(beyond  the  frontal  plane)  can  be  obtained  if  desired.     The  head  being  low 


Fig.  1058. 

down  the  thigh  may  still  be  in  a  position  of  marked  flexion.  It  is  then  flexed 
and  extended  by  the  pump-handle  movement  of  Hoff a  until  it  is  at  right 
angles  to  the  long  axis  of  the  body  when  the  plaster  cast  can  be  applied.  The 
limb  can  be  placed  in  either  external  or  internal  rotation.  If  the  latter,  then 
the  cast  extends  below  the  knee.  Traction  and  tearing  or  cutting  of  the 
muscles  are  not  practised  because  unnecessary,  athough  in  an  exceptionally 
difficult   case   tenotomy  of   the  adductor  longus   might   be  of   service.     The 


Fig.  1060. 

method  has  been  used  in  about  fifteen  cases.  In  one,  age  sixteen  years, 
It  failed.  In  another  aged  twelve  years  lacking  one  month,  it  took  four  attempts 
to  get  a  satisfactory  amount  of  abduction.  In  the  others  from  two  to  ten 
and  one  half  years,  satisfactory  reduction  was  accomplished  at  a  single  seance. 
Fixation :  Applying  the  Plaster  Bandage.— Reduction  having  been  ac- 
complished, the  child  is  turned  on  its  back  and  placed  on  a  pelvic  support 


894 


CONGENITAL   LUXATION    OF   THE  HIP. 


Fig.  io6i. 


(Fig.  io6i)  with  the  limbs  in  the  desired  position,  either  projecting  out  at  right 
angles  to  the  body  or  flexed  or  adducted  to  the  extent  desired.  We  put  the 
limb  up  in  extreme  abduction  for  the  first  dressing  and  invert  it  and  lessen 
the  abduction  at  the  second  dressing.  A  strip  of  flannel  bandage  is  laid  on 
the  leg  next  the  skin,  long  enough  to  project  considerably  beyond  the  edges 
of  the  plaster.  This  is  to  be  used  for  cleansing  purposes,  being  pulled  to  and 
fro  at  intervals  while  the  bandage  is  being  worn. 

The  limb  and  pelvis  is  covered  either  with  a 
flannel  bandage  or  stockinette  and  felt  pads 
placed  on  the  sides  of  the  pelvis  and  inner  sur- 
faces of  the  knee  to  avoid  pressure  sores.  The 
plaster  bandage  is  then  applied  in  the  form  of  a 
spica  embracing  the  thigh  and  pelvis.  If  in- 
ternal rotation  is  desired,  the  plaster  must 
include  a  part  of  the  leg  below  the  knee.  In 
order  to  strengthen  the  bandage  and  prevent 
reluxation  a  strip  of  strap-iron  can  be  placed  in  the  posterior  part  of  the 
bandage  running  down  from  the  pelvis  to  the  thigh.  Felt  pads  can  be  placed 
beneath  this  strip  between  it  and  the  trochanter  so  as  to  force  and  maintain 
the  head  as  far  anterior  as  is  desired  (Fig.  1062).  If  both  limbs  are  placed  in 
internal  rotation  as  suggested  by  Schede  and  advised  by  Mueller  the  patient 
sleeps  on  a  suspended  or  supported  Bradford  frame  (Fig.  1063)  with  the  legs 
hanging  down  over  its  sides.  If  only  one  side  is  involved  the  patient  can 
sleep  on  an  ordinary  bed  with  the  leg  hanging  over 
its  edge. 

The  first  plaster  dressing  is  left  on  from  one  to 
three  or  five  months.  If  the  tendency  to  reluxation  is 
slight  the  dressings  are  changed  at  short  intervals;  if 
the  tendency  to  reluxate  is  marked  the  dressings  are 
kept  on  longer.  In  favorable  cases  in  young  children 
a  single  dressing  will  suffice.  In  others  the  limb  will 
have  to  be  brought  down  gradually  at  each  change  of 
bandage.  From  three  months  to  nine  months  or  even 
longer  may  elapse  before  all  retaining  bandages  are 
discarded.  Lorenz  has  laid  considerable  stress  on  sub- 
sequent massage  and  gymnastics,  but  if  the  reposition 
and    stability    of    the    joint    are    good    they   are   not 

especially  needed,  especially  if  the  muscles  have  not  been  unduly  injured  by 
a  preliminary  (I  believe  unnecessary)  mobilization. 

If  both  hips  are  luxated,  nearly  all  surgeons  prefer  to  reduce  them  simulta- 
neously instead  of  treating  them  one  after  the  other.  If  the  hips  are  operated 
on  simultaneously  the  child  is  disabled  on  both  sides  and  locomotion  is  prac- 
tically impossible  until  the  limbs  are  brought  down  at  subsequent  dressings. 
If,  however,  only  one  has  been  operated  on,  then,  if  the  cast  is  satisfactory, 


Fig.  1062. 


IMMOBILIZATION. 


895 


the  child  can  go  around  on  crutches  or  a  high  shoe  in  two  or  three  days. 
In  cases  near  the  age  limit  preliminary  weight  extension  in  bed  for  two  to  four 
weeks  with  the  leg  in  an  abducted  position  may  be  tried. 

In  some  instances,  particularly  in  double  luxations,  difficulty  may  be 
experienced  in  bringing  the  limbs  down  parallel.  When  such  is  the  case  a 
strip  of  metal  may  be  incorporated  in  the  bandage  running  across  from  the 


Fig.  106^. 


inside  of  one  thigh  to  that  of  the  other  just  above  the  knees.  This  will  tend  to 
prevent  abduction.  If  the  plaster  cast  has  been  removed,  Lorenz  advises 
the  use  of  an  elastic  band  passing  across  from  one  knee  to  the  other.  To  en- 
able a  patient  with  a  one-sided  luxation  to  go  around,  a  high  pattern  or  shoe 
is  used  on  the  affected  leg  (Fig.   1064). 

Double  luxation  cases  can,  as  suggested  by  Lorenz,  be  given  a  small  bench 
with  rollers;  by  sitting  astride  it  the  child  can  push 
itself  along  (Fig.  1065). 

As  pointed  out  by  Gourdon,  Kirmisson,  and 
others,  when  the  limb  is  placed  in  extreme  abduc- 
tion the  head  is  not  ^pointing  correctly  into  the 
acetabulum,  but  is  looking  more  forwards.  Hence 
if  this  position  is  maintained  too  long  the  anterior 


Fig.  1064. 


Fig.  1065. 


part  of  the  joint  is  weakened  and  an  anterior  transposition  may  result. 
For  this  reason  it  is  best  to  change  the  position  of  the  limb  as  soon  as 
possible,  without  reluxation  occurring,  from  the  primary  position  of  extreme 
abduction  to  one  of  moderate  internal  rotation,  at  the  same  time  bringing 
the  limb  down  a  little  or  even  to  about  45°,  the  head  then  bores  directly 
into  the  socket  and  is  about  perpendicular  to  the  lateral  pelvic  plane.     The 


896  CONGENITAL   LUXATION    OF   THE  HIP. 

greater  the  amount  of  anteversion  of  the  head  and  neck  that  is  present  the 
greater  is  the  amount  of  internal  rotation  necessary.  In  cases  with  extreme 
anteversion  of  the  neck  an  osteotomy  to  correct  it,  as  advised  by  Kirmisson 
may  be  necessary,   but  that  is  very  rare. 

Results. — It  is  practically  impossible  to  give  an  accurate  statement  of 
results.  What  one  operator  calls  a  good  result  another  will  call  bad;  what  one 
calls  an  eccentric  replacement,  another  will  call  a  reluxation.  Le  Damany 
has  called  attention  to  the  unreliability  of  the  statments  of  the  mother  as  to 
the  great  improvement  effected.  Certain  it  is  that  with  a  judicious  amount 
of  suggestion  on  the  part  of  the  surgeon  the  parents  at  times  may  be  persuaded 
to  do  and  see  almost  anything.  One  fact,  however,  is  evident  and  that  is  that 
the  methods  of  replacement  as  well  as  of  subsequent  treatment  as  now  generally 
employed  have  not  changed  materially  since  their  general  introduction. 

Lorenz,  at  the  Lisbon  International  Congress  in  1906,  stated  that  ideal 
results  were  obtained  in  50  per  cent.,  and  of  the  other  50  per  cent,  the  geater 
part  were  transpositions  below  the  anterior  superior  spine  of  the  ilium. 

Kirmisson  at  the  same  congress  stated  that  in  twenty-eight  unilateral 
cases,  two  were  found  impossible  of  reduction  and  that  good  or  even  perfect 
results  were  obtained  in  eleven,  or  39  per  cent.  Of  twenty-four  double  cases 
only  two  had  good  permanent  results.  The  results  in  double  luxations  are 
about  one-half  as  good  as  in  single  luxations.  Many  operators  claim  more 
than  50  per  cent,  cures,  especially  in  single  luxations. 

The  fact  remains  that,  according  to  Lorenz,  and  his  statement  is  probably 
close  to  the  truth,  there  are  50  per  cent,  more  or  less  imperfect  results. 

He  claims  that  in  the  transpositions  or  what  he  calls  "lateral  apposi- 
tion," cases  below  and  a  little  outside  the  anterior  spine,  while  the  limping 
is  not  improved  the  endurance  is  and  that  they  do  not  tend  to  luxate 
posteriorly. 

We  would  like  to  agree  with  him  in  his  view,  but  at  present,  at  least,  cannot. 
While  the  treatment  undoubtedly  does  permanently  benefit  many  of  the  cases 
in  others  the  condition  seems  to  get  worse  rather  than  remain  stationary  until 
the  cases  can  scarcely  be  distinguished  from  those  who  have  had  no  treatment 
at  all.  In  other  words,  we  class  transpositions  under  the  head  of  failures, 
not  total,  it  is  true,  but  far  from  satisfactory.  So  distrustful  of  the  results  of 
the  bloodless  reposition  is  Sherman,  of  San  Francisco,  that  he  advocates 
replacement  by  open  operatipn,  not  making  a  new  acetabulum,  but  apposing 
cartilage  to  cartilage.  His  statistics  as  quoted  by  Kirmisson  are:  In  twenty- 
eight  cases  in  twenty  children  there  were  seventeen  good  results  two  months 
to  six  years  after  operation. 

Personally,  the  difiiculty  experienced  has  not  been  in  the  reduction,  but 
in  maintaining  the  reduction.  There  seems  to  be  little  doubt  that  in  some 
cases  the  acetabulum  is  so  shallow  as  to  absolutely  fail  to  give  proper  fixation 
for  the  head  of  the  femur. 

When  it  becomes  evident,  after  a  thorough  trial  of  fixation,  that  it  is  im- 


OPEN    OPERATION. 


897 


possible  to  get  a  stable  joint  then  we  believe  that  at  present  the  best  plan  is 
to  make  an  anterior  incision  and  deepen  the  acetabulum. 

Reduction  by  Open  or  Cutting  Operation. — It  is  also  to  the  Italians  that 
the  credit  belongs  of  being  the  first  to  indicate  the  proper  means  to  treat  other- 
wise irreducible  cases  by  operative  means.  Alfonzo  Poggi,  of  Bologna  ("  Arch- 
ivio  di  Ortopedia,"  1888),  on  January  29,  1888,  replaced  the  unresisted  head 
as  nearly  as  possible  in  a  newly  scooped-out  acetabulum  by  open  incision. 
Many  operations  had  been  done  before  that  time,  but  they  were  mainly  on  the 
muscles  or  resections  of  the  head  of  the  femur.  Two 
years  later  Hoffa  brought  out  his  well-known  method, 
and  it  is  to  him  that  the  world  is  indebted  for 
placing  the  operation  on  a  firm  basis  and  causing 
its  worth  to  be  generally  recognized. 

Hoffa  at  first  used  Langenbeck's  incision  which 
is  a  longitudinal  one  over  the  posterior  portion  of 
the  joint.  He  also  detached  the  muscles  from  the 
great  trochanter.  Later  he  made  an  incision  begin- 
ning .5  cm.  (1/5  inch)  in  front  of  the  upper  end  of 
the  anterior  edge  of  the  greater  trochanter  and  pro- 
longed downwards  for  6  cm.  (2  2/5  inches)  in  front 

of  the  trochanter.  Lorenz  modified  Hoiia's  operation  by  making  his  incision 
6  to  7  cm.  long  downwards  and  backwards  from  just  behind  the  anterior 
superior  spine  to  the  greater  trochanter.  It  passed  along  the  posterior  border 
of  the  tensor  fasciae  femoris  muscle.  He  avoided  the  division  of  the  muscles. 
The  operation  so  performed  has  been  called  the  Hoffa-Lorenz  operation. 

The  writer  operates  as  follows:  An  incision  (Fig.  1066)  three  or  four  inches 
long  is  made  directly  downwards  from  the  anterior  superior  spine.  The  fascia 
lata  is  split  and  the  sartorius  and  iliacus  muscles  pulled  inwards  and  the  tensor 
fasciae  femoris  and  anterior  edges  of  the  gluteus  medius  and  minimus  pulled 


J'IG.    1066. 


Fig.  1067. 


outwards.  The  separation  of  these  muscles  is  made  by  blunt  dissection  in  the 
line  of  the  incision  and  exposes  the  capsule  of  the  joint  and  the  neck  of  the 
femur.  The  capsule  is  freely  opened  and  the  finger  introduced  downwards 
to  determine  the  amount  of  contraction  of  the  capsule  and  the  condition  of 
the  acetabulum  below.  If  any  remnants  of  the  ligamentum  teres  are  present 
they  are  to  be  cut  away.  If  there  is  sufficient  contraction  of  the  capsule  to 
prevent  the  access  of  the  head  to  the  acetabulum,  then  a  dilator  is  introduced 
and  the  fibrous  structures  stretched.  For  this  purpose  Pryor's  uterine  dilator, 
57 


898 


CONGENITAL   LUXATION    OF   THE  HIP. 


being  very  powerful,  is  well  adapted  (Fig.  1067).  If  the  acetabulum  is  suffi- 
ciently empty  and  well-formed,  attempts  at  reduction  can  at  once  be  made. 

If  the  acetabulum  is  either  filled  with  fibro-fatty  material  or  is  too  shallow 
to  securely  lodge  the  head  of  the  femur,  then  it  is  to  be  cleansed  out. 

This  may  be  done  with  a  wood  carver's  gouge,  which  is  sharply  beveled  on 


Fig.  1068. 

its  outer  surface  (Fig.  1068),  or,  what  is  not  so  good,  with  a  sharp  Volkmann 
curette.  To  further  smooth  the  cavity  and  even  undercut,  if  necessary,  the 
writer's  rose  burr  (see  Fig.  1069)  will  be  found  of  service.  It  has  cutting  blades 
on  only  half  of  its  circumference  in  order  to  avoid  wounding  the  head  of  the 
femur.  Attempts  at  reduction  may  now  be  made  by  the  usual  procedures 
of  Paci  or  Lorenz.     If  these  fail,  then  the  writer's  lever,  shown  in  figure  1070 


Fig.  1069. 


may  be  tried.  The  small  or  large  blade,  which  can  be  reversed  for  use  on  the 
opposite  sides,  is  used  according  to  the  size  and  age  of  the  patient.  One  end 
is  hooked  under  the  edge  of  the  acetabulum  while  the  other  passes  over  the 
head  of  the  femur  (Fig.  107 1).  By  depressing  the  lever  and  abducting  the 
femur  the  head  can  be  made  to  enter  the  acetabulum.  Should  more  space 
be  necessary  for  the  manipulations,  the  tissues  may  be  detached  from  the 


Fig.  1070. 

crest  of  the  ilium  back  from  the  anterior  superior  spine  as  recommended  by 
Codivilla.  On  the  completion  of  the  reduction  these  are  again  to  be  sewn 
in  place  with  chromic  catgut  and  the  capsule  and  deep  parts  of  the  wound  also 
closed  as  much  as  possible.  A  rubber  drain  is  to  be  inserted,  but  is  to  be 
removed  in  twenty-four  hours. 


DAVIS  S    OPERATION. 


899 


In  operating  the  greatest  care  is  to  be  taken  not  to  injure  the  cartilaginous 
covering  of  the  head  of  the  femur.  Removal  of  the  cartilage  and  exposure 
of  the  bare  bone  of  both  the  head  of  the  femur  and  acetabulum  is  liable  to 
lead  to  anchylosis  or  restriction  of  motion.  The  limb  is  to  be  put  up  in  plaster 
of  Paris  in  a  sufficiently  abducted  and  extended  position  to  prevent  reluxation. 
The  plaster  m.ay  be  removed  every  three  or  four  weeks  and  passive  motion 
made.  It  may  be  discarded  in  ten  or  twelve  weeks.  Should  it  be  found  to  be 
absolutely  impossible  to  replace  the  head  in  the  acetabulum,  then  a  new  one 


Fig.  1071. 

should  be  dug  out  of  the  side  of  the  ilium  and  the  head  placed  therein.  This 
will  give  a  stable  support,  but  of  course  increases  the  shortening.  Anchylo- 
sis is  not  likely  to  occur  if  the  cartilage  on  the  head  of  the  femur  is  kept  intact. 
While  the  cutting  operation  is  regarded  unfavorably  by  many,  the  writer  has 
found  it  to  be  very  satisfactory.  It  must  he  admitted,  however,  that  the  opera- 
tion is  a  difficult  one  and  demands  a  skilled  technic  both  from  the  standpoint 
of  asepsis  and  reduction.  It  is  the  only  thing  that  gives  a  fair  promise  of  a 
stable  and  satisfactorv  result. 


CHAPTER  LXXXIII. 
KNEE-JOINT. 

PUNCTURE.     LAVAGE.     INJECTIONS. 

Puncture  of  the  knee  is  most  commonly  practised  to  withdraw  serous  effu- 
sions, recent  blood  extravasations,  etc.,  and  as  a  preliminary  to  lavage  and  the 
injection  of  various  curative  agents.  The  preparation  of  the  patient,  surgeon, 
assistants,  and  material  must  be  as  careful  as  if  for  an  arthrectomy. 

Step  I. — At  the  chosen  point  a  little  above  and  external  to  the  patella  inject 
a  few  drops  of  cocaine  or  analogous  solution  into  the  skin.  With  a  tenotome 
puncture  the  skin.  Through  the  puncture  pass  a  trocar  and  cannula  down- 
wards and  inwards  in  such  a  fashion  that  its  point  is  made  to  touch  the  articular 
surface  of  the  patella.     This  insures  that  the  instrument  has  entered  the  joint. 

Step  2. — Withdraw  the  stilette.  Let  the  fluid  escape.  Clots  of  fibrin  may 
plug  the  cannula;  these  may  be  removed  by  a  probe.  If  nothing  further  is 
required,  remove  the  instrument  and  apply  a  dressing  which  will  exercise 
elastic  pressure  on  the  knee.  If  it  is  desired  to  practise  lavage  or  injection, 
proceed  to  Step  3. 

Step  3. — With  an  irrigator,  or  better,  a  common  glass  syringe  connected 
with  the  cannula  by  sterile  rubber  tubing,  fill  the  joint  with  salt  solution  or  some 
mild  antiseptic;  disconnect  the  syringe  from  the  cannula;  permit  the  fluid  to 
escape;  repeat  this  washing  as  often  as  may  seem  necessary.  If  the  disease  is 
simple  hydrops  articuli  many  surgeons  follow  the  lavage  by  injecting  about 
three  drams  of  5  per  cent,  carbolized  water.  When  tuberculosis  is  present 
one  may  inject  the  same  quantity  of  a  sterile  emulsion  of  iodoform  in  glycerine 
(10  per  cent,  to  20  per  cent.)  J.  B.  Murphy  uses  the  following  emulsion; 
Iodoform,  10  per  cent. ;  formalin,  2  per  cent. ;  glycerine,  q.  s.  In  empyema  of  the 
knee  Murphy,  after  puncture  and  lavage,  injects  a  sufficiency  of  a  2  per  cent, 
solution  of  formalin  in  glycerine  to  produce  a  mild  amount  of  tension  in  the  joint. 
He  also  uses  this  injection  as  a  preliminary  to  most  arthrotomies,  as  he  believes 
the  simple  arthritis  produced  by  it  acts  as  an  immunizing  agent  against  infection 
during  the  major  operation.  In  cases  of  truamatic  dry  arthritis  Rovsing  omits 
all  lavage,  notes  that  no  fluid  escapes  through  the  cannula  (if  any  turbid 
fluid  escapes  injection  of  vaseline  is  contraindicated)  and  then  injects  about 
10  or  12  c.c.  of  sterfle  vaseline  (see  p.  853). 

Step  4. — Withdraw  the  cannula.  If  necessary,  close  the  puncture  with  a 
stitch.  Apply  dressings  and  a  splint  or  light  starch  bandage.  Keep  the  patient 
in  bed  for  a  few  days  and  then  permit  him  to  go  about  with  crutches.  The 
injection  may  be  repeated  in  from  two  to  six  weeks.     The  treatment  is  not 

900 


ARTHROTOMY. 


901 


suitable  when  osteal  lesions  are  present.     If  there  is  no  marked  improvement 
after  two  or  three  weeks,  abandon  the  method. 

Sclerogenic  Injections  (Lannelongue). — Nature  seems  to  cure  tuber- 
culous foci  by  imprisoning  them  in  an  impenetrable  capsule  of  fibrous  tissue. 
Lannelongue  has  sought  to  stimulate  nature  to  produce  this  capsule.  His 
method  is  as  follows:  Cleanse  the  parts  to  be  operated  on.  Charge  an  aseptic 
hypodermic  syringe  with  a  10  per  cent,  solution  of  chloride  of  zinc.  Inject 
8  to  10  minims  of  this  solution  at  each  of  various  points  around  the  diseased 
area.  These  injections  must  be  made  into 
healthy  tissue,  but  immediately  adjoining 
the  disease.  The  irritating  chloride  of  zinc 
is  supposed  to  lead  to  the  formation  of  scar 
tissue.  Excellent  results  have  been  claimed, 
but  the  method  has  not  become  very 
popular. 

Arthrotomy  Knee. — Arthrotomy  may 
be  performed  for  several  purposes,  (a) 
Exploratory;  (b)  for  the  removal  of  fluids, 
e.  g.,  serous  effusion,  blood,  pus;  (c)  as  a 
preventive  measure  after  infected  or  sus- 
pected wounds;  (d)  as  a  substitute  for 
puncture  and  injection;  here  the  wound 
must  be  closed  after  the  selected  remedial 
fluid  has  been  introduced;  (e)  for  the  re- 
moval of  foreign  bodies;  (f)  as  a  step  in 
other  operations  on  the  knee. 

Murphy,  whenever  possible,  prepares 
the  joint  by  injecting  glycerine-formalin 
solution  (p.  900)  a  week  or  ten  days  before 
performing  arthrotomy.  Arthrotomy  may 
be  performed  in  several  ways: 

(A)  Antero-Iateral  Incision. — For  ex- 
ploratory purposes  or  if  serous  or  bloody 
fluid  is  alone  present,  make  an  incision  one  finger's  breadth  external  to  the 
patella  from  the  level  of  the  lower  edge  of  the  patella  to  a  point  about  two 
fingers'  breadth  above  the  upper  end  of  the  patella  (Fig.  1072).  This  incision 
is  slightly  curved,  the  concavity  being  towards  the  patella.  Divide  the  skin 
and  fascia.  WTien  the  synovialis  is  reached  pick  it  up  with  forceps  and  cut 
between  the  forceps  so  as  to  open  the  joint.  Enlarge  the  wound  in  the  synovi- 
alis with  scissors  so  as  to  gain  access  to  the  upper  pouch  of  the  joint.  Of 
course  under  certain  circumstances  a  smaller  incision  suffices  and  should  be 
made;  for  exploration  and  for  m.any  other  purposes  the  larger  cut  described  is 
essential.  If  pus  is  present  or  if  the  single  incision  is  insufiicient,  make  an 
identical  cut  on  the  opposite  side  of  the  patella  (Fig.  1073).     If  drainage  is  re- 


FlG. 


(Lahev.) 


902 


KNEE-JOINT. 


quired  the  wounds  may  be  left  open  and  loosely  filled  with  gauze,  or  a  rubber 
drainage-tube  may  be  pulled  through  under  the  quadriceps  tendon,  from  one 
to  the  other. 

(B)  The  above  incisions  may  not  provide  sufficient  drainage  for  the  joint 


Fig.   1073. — {Labey.) 


cavity  near  the  popliteal  space,  hence  it  may  be  necessary  to  supplement  them 
by  postero-lateral  incisions  on  one  or  both  sides.  These  are,  under  the  cir- 
cumstances,   mere    counter-openings.     A    postero-lateral    counter-opening  is 

conveniently  made  as  follows:  Pass  a  closed 
forceps  through  the  antero-lateral  wound 
(Fig.  1074),  through  the  joint  and  make  it 
raise  up  the  soft  parts  on  the  outer  side  just 
anterior  to  the  hamstrings,  thus  avoiding 
the  external  popliteal  nerve;  on  the  inner 
side  it  may  go  between  the  tendons.  With 
a  knife  make  a  longitudinal  cut  so  as  to 
expose  the  forceps,  seize  the  end  of  a  rubber 
tube  in  the  forceps  and  with  it  pull  the  tube 
through  the  wound.  Postero-lateral  inci- 
sions may  and  often  are  made  as  the  primary 
incision,  especially  in  cases  of  pyarthrosis,  as 
they  by  themselves  give  good  access  not  only 
to  the  joint,  but  also  to  those  popliteal  bursae  which  most  commonly  com- 
municate with  the  joint.  The  operation  is  as  follows: 
(a)  On  the  outer  side. 


Fig.  1074. — {Labey.) 


ARTHROTOMY.  903 

Step  I. — Extend  the  knee.  Palpate  the  tendon  of  the  biceps.  Make  an 
incision  about  21/2  inches  long,  just  in  front  of,  and  parallel  to  the  tendon. 
This  cut  extends  nearly  down  to  the  head  of  the  fibula  and  divides  the  skin  and 
fascia. 

Step  2. — Slightly  flex  the  knee  so  as  to  expose  the  anterior  border  of  the  biceps 
tendon.  Retract  the  tendon  backwards  and  expose  the  posterior  border  of  the 
external  condyle  of  the  femur. 

Step  3. — Open  the  capsule.  Introduce  the  gloved  finger  into  the  joint  and, 
guided  by  it,  enlarge  the  opening  as  may  be  necessary. 

(b)  On  the  inner  side. 

Step  I. — The  knee  being  extended,  flex  the  thigh  on  the  pelvis.  This  permits 
one  to  see  and  palpate  a  longitudinal  groove  beside  and  behind  the  internal 
condyle.  The  inner  border  of  the  groove  is  formed  by  the  gracilis  (coming  from 
the  pubis),  the  outer  border  by  the  semi-tendinosus  coming  from  the  ischium. 
Make  a  longitudinal  incision  in  the  above  groove.  The  middle  of  the  incision 
should  be  opposite  the  line  of  the  knee-joint.  Divide  the  skin  and  fascia. 
Expose  the  sartorius  and  half  hidden  by  it,  the  gracilis.  To  the  popliteal  side 
of  these  tendons  note  the  narrow  tendon  of  the  semi-tendinosus  and  more 
deeply  situated  the  big  semi-membranosus  tendon.  Retract  these  tendons 
forwards. 

Step  2. — Open  the  joint  on  the  posterior  border  of  the  internal  condyle  of  the 
femur  by  an  incision  reaching  from  the  border  of  the  meniscus  to  the  upper  end 
of  the  capsule.  If  there  is  a  serous  bursa  under  the  semi-membranosus,  it  is 
easily  felt  by  the  finger  and  opened.  Instead  of  providing  tubuar  drainage  after 
postero-lateral  incision,  it  has  been  advised  to  unite  the  posterior  lip  of  the 
synovial  wound  to  the  skin  by  one  or  two  catgut  sutures.  To  obtain  perfect 
drainage  it  is  recommended  that  the  knee  be  kept  flexed  at  an  angle  of  at  least 
20  degrees. 

(C)  Arthrotomy  by  Transverse  Incision. — Dislocation  Method. — 
This  operation  may  be  performed  in  several  ways: 

(i)  Transverse  Section  of  the  Patella.— Make  an  incision  from  one  condyle 
of  the  femur  to  the  other  across  the  middle  of  the  patella.  Divide  the  patella 
transversely  with  a  saw.  With  knife  or  scissors  divide  the  lateral  ligaments, 
etc.,  so  as  to  open  the  joint  to  the  full  extent  of  the  cutaneous  wound.  Strongly 
flex  the  knee  and  divide  the  crucial  ligaments.  Pull  the  upper  fragment  of  the 
patella  and  the  soft  structures  around  it  strongly  upwards  so  as  to  expose  fully 
the  upper  synovial  pouch,  to  do  this  lateral  incisions  may  be  necessary.  Pull 
the  lower  fragment  of  patella  downwards  so  as  to  expose  the  lower  articular 
pouches.  Keep  the  knee  flexed  to  such  an  extent  that  the  whole  popliteal 
surface  of  the  joint  is  exposed  but  no  injurious  compression  is  exerted  on  the 
popliteal  vessels.  After  cleaning  the  joint  cavity  and  swabbing  with  Harring- 
ton's solution  or  its  equivalent  fill  it  loosely  with  gauze  and  apply  abundant 
dressings.  Keep  the  limb  flexed  as  noted  above  and  watch  the  circulation  of 
the  foot  carefully  lest  it  be  impeded  by  too  great  flexion  of  the  knee. 


904 


KNEE-JOINT. 


Note. — Some  surgeons  do  not  cut  the  crucial  ligaments,  but  this  seems  to 
be  essential  in  bad  cases. 

(2)  Curved  Incision. — Reflection  of  Patella  Upwards  (Peck). — Make 
a  horseshoe-shaped  incision  from  the  posterior  border  of  one  condyle  to  a 
corresponding  point  on  the  other  condyle  (Fig.  1075).     The  incision  is  convex 


Fig.  1075. — {Peck.) 

downwards  and  divides  the  tendo  patelke.  Divide  the  anterior  capsule,  both 
lateral  and  both  crucial  ligaments,  leaving  the  posterior  ligaments  alone  intact. 
Make  a  lateral  cut  on  each  side  upwards  so  as  to  permit  the  complete  turning 
upwards  of  the  anterior  flap,  including  the  patella  and  all  tissues  down  to  the 
joint  (Fig.  1076).     This  exposes  every  nook  and  cranny  of  the  upper  synovial 


PECK  S    METHOD. 


905 


pouch.  Keep  the  patellar  flap  in  its  new  position  by  means  of  a  stitch 
uniting  it  to  the  skin  of  the  thigh.  The  rest  of  the  operation  is  the  same  as  that 
already  described.  After  recovery  from  the  infective  process  has  taken  place, 
Peck  and  others  recommend  performing  arthrectomy,  arguing  that  even  if  it 
was  possible  to  obtain  closure  of  the  wound  without  removing  the  articular 


Fig.   io-]6.~{Peck.) 


surfaces,  yet  there  would  be  no  chance  of  getting  a  useful  joint  and  there  would 
be  a  probability  of  fibrous  anchylosis  with  subluxation  of  the  tibia  on  the  femur. 
To  the  author  it  seems  wise  not  to  adopt  any  hard  and  fast  rule;  if  reduction  and 
retention  of  the  articular  surfaces  in  proper  position  is  easy  then  endeavor  to 
obtain  a  more  or  less  mobile  joint,  if  this  fail  it  is  easy  to  resect  at  a  later  date. 


906  KNEE-JOINT. 

Remarks  on  Arthrotomy. — \\Tieii  exploration  of  the  knee  is  demanded 
the  external  antero-lateral  incision  is  commonly  the  best;  under  special  cir- 
cumstances, e.  g.,  the  presence  of  a  palpable  foreign  body  on  the  inner  side, 
the  incision  may  be  made  on  the  inner  side  or  directly  over  the  foreign  body. 

Serous  or  bloody  effusions  are  readily  removed  through  the  antero-lateral 
incision  on  one  or  both  sides.  In  these  conditions  after  evacuation  of  the 
joint  and  irrigation  with  salt  solution  the  wound  may  be  closed  with  or  without 
drainage.  WTien  the  fluid  present  is  purulent  much  depends  on  the  virulence 
of  the  infection  and  the  evidences  of  sepsis.  In  cases  of  mild  infection  drainage 
may  be  established  through  antero-lateral  incisions  or  such  may  be  supplemented 
by  postero-lateral  counter-openings.  When  the  infection  is  more  severe, 
postero-lateral  incisions  are  preferable,  the  wounds  being  left  open  or  the  poste- 
rior edge  of  the  cut  in  the  synovialis  may  be  temporarily  sutured  to  the  skin. 
Through  lateral  incisions  the  author  has,  on  a  number  of  occasions,  made 
extensive  resection  of  necrosed  synovialis  and  capsular  tissues  and  has  been 
astonished  by  obtaining  a  useful  movable  joint,  although  the  large  lateral  wounds 
were  left  wide  open  after  being  loosely  packed  with  gauze.  When  the  infection 
is  very  virulent  and  absorption  is  great  the  preceding  methods  are  insufficient. 
It  is  necessary  to  so  expose  the  wJiole  interior  of  the  joint  that  loose  gauze  dress- 
ings may  be  applied  to  every  part  of  it  in  such  a  fashion  that  it  will  be  easier 
for  the  septic  products  to  be  soaked  up  by  the  dressings  than  absorbed  by  the 
lymphatics.  For  this  purpose  the  transverse  incision  is  appropriate  and  has 
proved  a  very  life-saving  measure. 

In  suppurative  cases  it  is  wise,  after  evacuating  the  pus,  to  remove  any 
masses  of  necrotic  tissues.  If  these  tissues  are  dissected  away  (scraping  vdth 
a  sharp  spoon  is  often  ineffective),  one  should  remember  that  the  dissection 
opens  up  fresh  avenues  of  absorption,  hence  the  wound  should  be  swabbed 
with  tincture  of  iodine,  Harrington's  solution  or  liquid  carbolic  acid.  If  the 
carbolic  acid  is  applied,  its  effects  should  be  neutralized  by  swabbing  with  alco- 
hol. After  treating  the  joint  by  the  "dislocation  method"  with  or  without  sub- 
sequent resection  of  the  bone,  anchylosis  is  most  likely  to  result.  This  is  of  little 
moment  as  the  operation  is  not  one  of  convenience,  but  an  urgent  radical  meas- 
ure to  save  life  and  avoid  amputation. 

The  difficulty  of  drainage  of  the  knee-joint  in  the  dorsal  decubitus  leads 
Flint  to  recommend  the  ventral  posture. 

Sixty  per  cent,  of  all  penetrating  wounds  (traumatic)  of  the  knee  become 
infected  (Flint).  This  being  the  case  one  ought  to  enlarge  the  wound  as  much 
as  necessary  so  as  to  cleanse  it  and  to  remove  all  foreign  bodies  which  may 
have  been  introduced.  The  cleansing  of  a  punctured  wound  is  notoriously 
difficult,  hence  in  such  cases  it  is  probably  wise  to  provide  lateral  drainage 
until  the  dangers  of  infective  arthritis  have  passed.  Operation  for  punctured 
wound  of  the  knee,  if  done  by  a  practitioner  not  thoroughly  sure  of  his  aseptic 
technic  and  especially  if  carried  out  in  unfavorable  surroundings  is  not  to  be 


LOOSE    BODIES. 


907 


recommended,  as  the  dangers  from  the  operation  would  be  greater  than  those 
from  the  original  trauma. 

Arthrotomy  for  the  Removal  of  Loose  Bodies. — Several  varieties  of 
organic  bodies  may  lie  loose  in  the  joint  and  cause  very  distressing  and  crippling 
symptoms.  The  bodies  may  be  single  or  multiple,  may  be  absolutely  free  or  be 
pedunculated.  The  bodies  may  occupy  almost  any  part  of  the  ca\'ity,  but  only 
give  rise  to  symptoms  when  nipped  between  the  articular  surfaces.  They  may 
be  very  movable  and  hence  are  liable  to  get  out  of  reach.  The  patient  by 
making  certain  movements  can  often  bring  the  body  into  a  superficial  positon. 


Fig.  1077. 


If  the  body  is  very  mobile  it  is  sometimes  wise,  after  thorough  cleansing  of  the 
parts,  to  harpoon  and  so  fix  it  with  a  sterile  needle.  It  it  then  easy  to  cut  down 
on  to  the  body  under  local  anaesthetic  and  remove  it  without  introducing  a  finger 
into  the  wound. 

Usually  a  general  anaesthetic  will  be  required  and  a  larger  incision  made  in 
order  to  explore  the  cavity  with  a  gloved  finger.  The  operation  is  essentially 
that  of  antero-lateral  arthrotomy.  When  a  delicate  pedicle  is  present  it  is 
easily  ruptured;  a  stronger  pedicle  may  require  a  snip  of  the  scissors.  The 
wound  is  closed  by  two  layers  of  sutures  without  drainage. 

Loose  bodies  can  often  be  demonstrated  by  the  X-rays,  but  a  warning  is 


9o8 


KNEE-JOINT. 


here  necessary.  In  the  gastrocnemei  muscles  there  are  often  present  small 
sesamoid  bones  (Fig.  1077),  which  may  be  mistakn  for  loose  bodies  in  the  joint. 

Displaced  Semilunar  Cartilage. — Internal  Derangement  of  the 
Knee-joint  (Hey). — Many  methods  have  been  devised  for  exposing  a  dis- 
placed semilunar  cartilage.  Annandale  in  1885  described  a  method  of  anchoring 
the  cartilage  through  a  simple  transverse  incision. 

Freeman  reflects  a  U-shaped  flap  of  all  the  tissues,  including  the  capsule, 
upon  the  internal  or  external  surface  of  the  joint,  as  required,  and  lying  between 


Fig.   1078. — {Freeman.) 

the  lateral  ligament,  on  one  hand,  and  the  patella  and  its  ligament  on  the  other 
(Fig.  1078). 

The  base  of  the  flap  may  either  be  upwards  or  downwards  but  it  must  be  so 
placed  as  to  freely  expose  the  upper  edge  of  the  tibia  and  the  semilunar  car- 
tilage. 

It  is  now  easy,  in  suitable  cases,  to  reduce  the  cartilage  and  fix  its  edge  to 
the  periosteum  by  a  few  stitches.  This  treatment  is  now  practically  discarded 
in  favor  of  excision  which  gives  as  good  results  and  more  insurance  against 
recurrence.  When  the  cartilage  is  exposed  seize  it  with  a  strong  hemostatic 
forceps  or  pull  it  outwards  with  a  blunt  hook.  Cut  it  from  its  moorings  with 
scissors  or  twist  it  until  it  tears  free.  Close  the  wound  in  the  capsule  and  fascia 
with  fine  catgut.  Close  the  skin  wound.  Dress.  Apply  a  posterior  splint 
or  a  starch  bandage.     Begin  gentle  motion  in  about  two  weeks.     Gradually 


TONES     METHOD. 


909 


increase  motion.     Massage  is  useful.     A  number  of  weeks  may  pass  before 
absolutely  free  and  comfortable  motion  is  possible. 

Jones'  Operation. — Robert  Jones  ("Annals  Surgery,"  Dec,  1909)  describes 
his  method  of  operating  as  follows:  "For  some  time  I  have  given  over  operating 
with  the  knee  in  such  a  position  that  it  has  to  be  further  flexed  during  the  pro- 
ceedings. Unless  the  greatest  care  is  taken,  the  clothes  get  shifted  or  air  is  in- 
troduced into  the  joint.  All  surgeons  of  experience  will  have  noted  this.  To 
avoid  this  risk  I  begin  the  operation  with  the  patient's  knee  hanging  at  right 
angles  over  the  foot  of  the  table  (Figs.  1079,  1080).  To  shift  during  the  oper- 
ation is  to  change  the  plane  of  the  incision.     The  final  cleaning  of  the  knee  takes 


Fig.  1079. — [R.  Jones.) 


place  while  the  joint  is  flexed  and  the  skin  tense.  Some  thicknesses  of  sterile 
gauze  squeezed  out  of  i  to  1000  biniodide  of  mercury  is  wrapped  round  the 
joint  and  the  incision  is  made  through  the  gauze,  the  cut  edges  of  which  are 
fixed  to  the  wound.  The  length  of  incision  which  practically  always  suffices 
is  three  inches,  the  incision  into  the  capsule  is  much  smaller  (Fig.  1080).  Long 
skin  incisions  obviously  add  to  the  risks,  and  are  only  very  exceptionally  needed. 
The  incision  should  be  slightly  curved  and  extend  from  an  inch  within  the  lower 
angle  of  the  patella  to  half  an  inch  below  the  tibial  margin,  curving  more  acutely 
at  this  point  towards  the  lateral  ligament.  The  interior  of  the  joint  is  then 
inspected  with  the  aid  of  carefully  applied  retractors.  No  less  authorities  than 
Sir  William  Bennett  and  Air.  AMiitelocke  advocate  entering  the  finger  for 
exploratory  purposes.     The  finger  should  never  enter  the  joint.     Neither  the 


9IO 


KNEE-JOINT. 


surgeon  nor  the  assistant  should  touch  the  wound  with  anything  but  sterile 
instruments.  The  sutures  for  the  capsule  should  be  handed  on  forceps  and 
I  usually  make  the  stitches  a  blanket-stitch.  In  the  flexed  position,  the  best 
view  is  obtained  of  the  interior  of  the  joint  and  the  cartilage  can  be  well  inspected 
If  the  capsule  plicates  and  hides  the  view,  draw  it  outwards  with  a  skeleton 
retractor  which  may  be  used  to  obtain  a  good  view  in  any  direction.  The 
cartilage  may  be  found  in  any  position.  It  may  be  detached  at  its  anterior 
extremity.  It  may  be  circumferentially  split;  it  may  be  completely  fractured; 
it  may  be  completely  twisted;  it  may  be  firmly  fixed  but  with  frayed  inner  border; 
it  may  be  nodular;  the  posterior  part  may  be  in  front;  it  may  be  attached  at 
its  extremities  and  free  along  the  whole  or  part  of  its  outer  border;  the  anterior 
part  may  be  ground  away,  or  found  quite  loose  as  a  separate  body,  or  only  the 
slightest  movement  may  be  possible,  due  to  loosening  of  its  moorings.     The 


Fig.  1080.  —  {R.  Jones.) 


examination,  which  should  be  gentle,  is  facilitated  by  a  sharp  or  blunt  hook. 
It  is  only  necessary  to  remove  the  loose  portion  of  the  cartilage,  be  it  a  frayed 
border,  a  circumferential  tear  or  a  detached  anterior  portion.  Here  I  would 
offer  a  practical  suggestion.  Never  pull  upon  the  cartilage  nor  cut  when  pulling; 
this  detaches  more,  and  to  my  knowledge  is  a  cause  of  recurrence. 

"Note  the  degree  of  detachment  and  go  a  short  distance  further  with  a 
knife  cutting  the  cartilage  clean  across,  and  then  complete  the  incision  along 
the  outer  border.  Having  removed  the  cartilage,  look  for  fringes,  tabs  or 
other  possible  agencies  which  may  cause  trouble  in  the  future,  and  remove 
them.  Stitching  the  cartilage  should  be  an  obsolete  operation.  If  the  cartilage 
is  only  slightly  mobile  and  the  history  characteristic,  it  should  be  removed 
forthwith.  During  the  operation,  dabs  taken  directly  from  the  sterile  drum 
should  cover  the  wound  during  any  interval,  and  no  dab  should  be  used  which 
has  been  exposed  to  the  air. 

"I  never  tie  vessels,  always  use  a  tourniquet  until  the  dressings  are  bandaged, 


JONES     METHOD.  9II 

and  never  drain.  I  used  to  drain,  years  ago,  but  I  consider  it  quite  unneces- 
sary, and  an  additional  communication  between  skin  and  joint.  The  synovial 
membrane  capsule  and  skin  should  be  separately  sutured  and  the  sutures  should 
not  pass  through  the  whole  thickness  of  the  skin.  I  now  know  no  anxious 
moments,  the  skin  never  reddens,  nor  do  I  have  trouble  with  effusion. 

"The  stitches  are  left  in  position  for  eight  days,  the  knee  kept  slightly  bent 
in  a  splint  for  the  same  period,  or  a  few  days  longer,  and  then  passive  move- 
ments and  massage  are  started.  Special  attention  should  be  paid  to  the  weak 
quadriceps  and  in  from  three  to  four  weeks  normal  exercise  should  be  allowed." 

James  Bell,  disliking  the  usual  transverse  or  vertical  incisions  because  of 
the  little  space  afforded  by  them  and  the  consequent  dangers  of  infection  due 
to  increased  manipulation,  opens  the  knee-joint  freely  by  a  transpatellar  in- 
cision (the  patella  being  sawn  through).  Bell's  method  seems  too  severe.  x\t 
the'end  of  the  operation  he  carefully  sutures  the  capsule,  etc.,  and  the  patella. 
Edmund  Owen  uses  a  3-inch  incision  to  the  inner  side  of  the  patella  and  usually 
finds  the  inner  cartilage  lying  across  the  top  of  the  internal  tuberosity  of  the 
tibia  and  perhaps  detached  from  the  internal  lateral  ligament;  if  so,  the  knee 
is  flexed  and  the  cartilage  cut  across  as  far  back  as  possible. 

In  operating  on  a  displaced  semilunar  cartilage  safety  demands  either  the 
use  of  rubber  gloves  or  strict  adhesion  to  Konig's  rule  never  to  put  a  finger  in 
the  wound. 

WTien  ought  we  to  operate  for  displaced  semilunar  cartilage  ? 

We  ought  never  to  operate  before  giving  conservative  means  a  fair  and 
protracted  trial.  Hence  acute  cases  are  not  for  operation.  Cases  without 
effusion  can  generally  be  kept  comfortable  or  cured  by  the  use  of  some  hinged 
apparatus  to  the  knee  or  even  by  raising  the  inner  side  of  the  heel  of  the  shoe 
so  as  to  make  the  patient  walk  in  a  pigeon-toed  fashion.  When  effusion  is 
present  (not  acute  synovitis)  or  when  there  is  crackling  on  motion,  operate. 
The  effusion  means  constant  irritation  and  injury  to  the  synovialis,  the  crack- 
ling generally  means  that  the  cartilage  has  become  rolled  upwards  and  joint- 
ward  more  or  less  like  a  pea. 

Excision  by  means  of  some  flap  exposure  is  the  operation  of  choice.  In 
the  "British  Med.  Journ.,"  Dec.  9,  1905,  Mr.  A.  E.  Barker  describes  some 
atypical  forms  of  internal  derangements  of  the  knee.  The  symptoms  and 
history  in  these  cases  are  identical  with  the  classical  lesion.  The  pain  and 
tenderness  are  on  the  inner  and  anterior  aspect  of  the  head  of  the  tibia.  After 
opening  the  joint  by  a  curved  internal  antero-lateral  incision  Barker  found  the 
meniscus  normal,  but  when  the  knee  was  flexed  and  the  tibia  rotated  outwards 
a  long  white  "tag"  of  dense  fibrous  tissue  was  seen  projecting  backwards  from 
the  loose  tissue  behind  the  patella.     On  the  removal  of  the  tag,  cure  resulted. 

Under  similar  circumstances  after  the  same  incision  Barker  found  no  dis- 
placement of  the  internal  cartilage,  no  retropatellar  "tags,"  but  beyond  the 
crucial  ligament  he  saw  a  white  mass  which  he  pulled  forwards  with  a  hook 
and  found  it  to  be  the  external  cartilage  attached  at  both  ends  but  torn  from 


912  KNEE-JOINT. 

the  coronary  ligament  by  an  injury  sustained  forty-four  years  before.  Remember 
that  flexion  and  external  rotation  of  the  knee  after  it  is  opened  may  reveal  the 
cause  of  disabling  symptoms  and  permit  of  cure.  Remember  that  the  synovi- 
alis  of  a  healthy  joint  only  feebly  resists  infection  and  hence  that  the  ungloved 
finger  must  never  touch  a  wound  made  in  a  joint. 

J.  B.  Murphy  always  endeavors  to  render  the  knee  immune  to  infection  by 
a  preliminary  injection  of  formalin-glycerine  (2  per  cent.). 

Repair  of  Ruptured  Crucial  Ligaments. — Mayo  Robson  operated  on  a 
a  man  for  lameness  resulting  from  a  severe  accident  sustained  nine  months 
previously  ("Clinical  Society,"  London,  Nov.  28,  1902).  Battle  operated  on 
a  case  in  similar  fashion.  "  On  admission,  the  right  knee  was  swollen  but  free 
from  tenderness.  When  the  muscles  were  pressed  the  bones  were  in  good 
position,  but  as  soon  as  the  muscles  were  relaxed  the  tibia  fell  backwards  until 
stopped  by  the  ligamentum  patellar,  and  on  manipulation  the  head  of  the  tii^ia 
could  be  brought  forwards  in  front  of  the  femur,  there  being  also  free  lateral 
movement  of  the  head  of  the  tibia  on  the  femur  and  some  fluid  in  the  joint. 
Not  only  were  all  the  ligaments  relaxel,  but  the  crucial  ligaments  had  been 
ruptured.  On  November.  21,  1895,  the  joint  was  opened  by  a  semilunar 
incision  carried  across  the  front  and  dividing  the  ligamentum  patellae.  The 
synovial  membrane  was  found  inflamed,  and  there  was  excess  of  fluid  in  the 
joint.  Both  crucial  ligaments  were  completely  ruptured,  having  been  torn 
from  their  upper  attachments,  the  ends  being  in  a  shreddy  condition.  They 
were  stitched  in  position  by  means  of  catgut  ligatures  and  the  anterior  being 
stitched  to  the  synovial  membrane  and  tissues  on  the  inner  side  of  the  external 
condyle,  and  the  posterior,  which  was  too  short  and  was  split  in  order  to  lengthen 
it,  was  fixed  by  sutures  to  the  synovial  membrane  and  cartilage  on  the  outer 
side  of  the  inner  condyle.  The  wound  was  then  stitched  up  by  means  of  buried 
catgut  sutures,  and  was  closed  superficially  by  interrupted  silkworm-gut 
sutures.  Complete  restoration  of  the  normal  movements  of  the  joint  occurred. 
The  stitches  were  removed  on  December  4,  and  on  the  fourteenth  plaster  of 
Paris  was  applied,  and  he  was  allowed  to  get  about  on  a  Thomas'  splint  and  to 
go  home.  The  plaster  was  removed  in  a  month,  after  which  movement  gradu- 
ally returned  under  massage.  When  seen  on  October  24,  1901,  the  patient 
was  walking  without  a  limp  and  could  run.  He  said  that  his  leg  was  perfectly 
strong,  and  that  he  could  work  eight  hours  a  day  at  his  old  employment  of  get- 
ting coal,  and  that  he  had  never  been  off  a  day  on  account  of  his  knee  since  the 
year  of  his  accident.  The  joint  could  be  extended  to  the  straight  line  and 
flexed  just  beyond  the  right  angle,  there  being  no  abnormal  lateral  or  antero- 
posterior mobility  whatever." 

Pringle  has  had  two  cases  of  injury  to  the  knee  in  which  abduction  while 
the  knee  was  extended  was  a  prominent  symptom.  In  both  cases  the  provisional 
diagnosis  was  ruptured  internal  lateral  ligament.  On  opening  the  knee  of 
one  of  these  cases  the  anterior  crucial  ligament,  still  attached  to  its  bony  inser- 
tion, was  found  to  be  torn  off  the  tibia,  taking  the  tibial  spine  with  it.     Pringle 


ARETHRCTOMY. 


913 


sutured  the  spine  in  place  and  obtained  a  good  result.     In  the  second  case, 
after  opening  the  knee,  the  anterior  crucial  ligament  was  found  torn  from  its 
femoral  attachment  and  was  then  sutured  by  Pringle  to  the  tissues  on  the  median 
side  of  the  external  condyle  ("Annals  of  Surgery,"  Aug.,  1907). 
Figure  108 1  will  remind  the  reader  of  the  anatomy  of  the  knee. 


Stump  of  ligamentum  mucosum 
External  semilunar  fibro- 
cartilage 


Bursa  under  quadriceps  extensor  tendon 
Patella 

Posterior  crucial  ligament 

Anterior  or  capsular  ligament 


Coronary  ligament 

Transverse  ligament' 
Anterior  crucial  ligament' 


Coronary  ligament 
Internal  semilunar  fibro-cartilage 


Fig.   io8r. — -{Deavcr.) 

Arthrectomy. — Excision. — The  term  arthrectomy  is  here  used  as  meaning 
the  removal  of  synovialis  either  alone  or  plus  excision  of  the  diseased  portions 
of  cartilage  and  bone.  The  term  excision  is  reserved  for  operations  where  the 
whole  articular  surfaces  are  formally  excised. 

Method  A. — Lateral  Incision. — Step  i. — Beginning  at  the  inner  side  of 
the  ligamentum  patellae,  make  a  curved  incision  upwards  and  backwards  to  the 
anterior  margin  of  the  internal  lateral  ligament  where  it  crosses  the  line  of  the 


914 


KNEE-JOINT. 


articulation;  continue  the  cut  upwards  over  the  internal  epicondyle  and  make 
it  curve  forwards  and  upwards  around  the  inner  and  upper  part  of  the  superior 
synovial  pouch  (Fig.  1082).  Beginning  at  the  outer  side  of  the  insertion  of 
the  ligamentum  patellae,  make  a  corresponding  incision  on  the  outer  side  of 
the  joint.  Both  these  incisions  penetrate  at  once  to  the  bone  in  the  lower 
part  of  the  incision,  while  in  the  upper  part  the  vasti  are  divided  and  the 
articular  capsule  is  exposed. 

Step  2. — Synovialectoiny. — With  sharp  retractors  elevate  the  anterior  edge 
of  the  wound  (on  the  outer  side)  from  the  capsule.  With  forceps,  knife,  and  scis- 
sors dissect  the  anterior  part  of  the  diseased 
capsule  from  the  soft  parts  covering  it,  until 
the  patella  or  the  middle  line  (Fig.  1083)  is 
reached.  Separate  the  upper  synovial  pouch 
from  all  its  surroundings.  Divide  the  syno- 
vialis  where  it  is  inserted  into  the  patella. 
Make  a  similar  dissection  through  the  internal 
wound  and  remove  the  separated  synovialis. 
Dislocate  the  patella  outwards  in  such  a  man- 
ner as  to  expose  its  under  surface  and  that  of 
the  quadriceps  and  the  patellar  tendons.  In- 
spect these  structures  and  remove  from  them 
any  shreds  of  synovialis  which  may  have  been 
left.  If  it  is  necessary  to  remove  the  synovialis 
from  the  popliteal  side  of  the  joint,  make  a 
partial  division  of  the  interal  lateral  ligament 
and,  if  necessary,  of  the  tendo  patellae.  Dislocate  the  joint  so  as  to  make 
the  articular  surface  of  the  femur  (or  tibia)  protrude  through  the  inner  wound. 
To  obtain  complete  exposure  it  is  necessary  to  divide  the  crucial  ligaments. 
With  great  care  dissect  away  the  synovialis  from  the  popliteal  surface. 

This  completes  the  synovialectomy.  If  no  more  disease  requires  removal, 
cleanse  the  wound.  In  tuberculous  cases  it  it  wise  to  rub  the  wound  with 
iodoform  powder.  If  possible  unite  the  crucial  ligaments  with  catgut  sutures. 
Repair  the  lateral  ligament  and  patellar  tendon.  Close  the  wound  with  or 
without  drainage. 

Step  3. — (a)  Bony  ancholylosis  is  desired  though  no  bone  is  diseased.  With 
a  strong  knife  or  with  a  chisel  pare  away  the  articular  cartilage  from  the  femur, 
tibia,  and  patella,  removing  also  the  remnants  of  the  crucial  ligaments  and  the 
semilunar  cartilages.     Close  the  wound  and  treat  as  a  fracture. 

(b)  Foci  of  disease  are  found  in  the  bones  to  a  limited  extent.  The  most 
common  lesions  are  foci  of  tuberculous  granulation-tissue  infiltrating  and 
absorbing  the  bone,  and  necrotic  foci.  If  the  active  advance  of  the  disease  has 
ceased,  the  diseased  foci  will  be  found  surrounded  by  a  mass  of  sclerosed  bone — 
a  favorable  sign.  With  a  sharp  spoon  or  a  gouge  remove  all  the  diseased  tissue. 
Necrotic  foci  are  often  so  intimately  attached  to  the  surrounding  bone  that  they 


Fig.  1082. 


ARTHRECTOMY. 


915 


Fig.  1083. 


Fig.  1084. 


9i6 


KNEE-JOINT. 


require  removal  by  means  of  chisel  and  mallet.  After  removal  of  the  disease 
swab  the  osseous  wound  with  tincture  of  iodine  or  rub  in  iodoform  powder  or  fill 
the  cavity  with  Mosetig's  bone  plug.  Close  the  wound  with  or  without 
drainage  and  treat  as  a  fracture. 

Step  4. — Excision  or  Resection  of  the  Joint. — Synovialectomy  or  exci- 
sion of  local  osseous,  foci  of  disease  is  inadequate:  it  is  necessary  to  remove 
the  articular  ends  of  the  bone.  Flex  the  hip.  Make  the  lower  end  of  the 
femur  protrude  through  the  wound  (Fig.  1084).  Apply  a  saw  at  right  angles 
to  the  femur  and  saw  ofif  the  articular  end  of  the  bone.  Be  careful  as  to  the 
line  of  section,  so  that  when  the  sawn  surfaces  of 
the  femur  and  tibia  are  approximated  the  patient  may 
have  a  straight  or  very  slightly  flexed  knee  without 
genu  valgum.  With  forceps  or  saw  remove  the 
posterior  sharp  edge  of  the  raw  surface  of  the  femur. 
Still  keeping  the  thigh  flexed,  push  the  articular  end 
of  the  tibia  upwards  so  as  to  be  clear  of  the  soft 
parts,  especially  those  of  the  popliteal  space.  Saw  a 
thin  slice  from  the  tibia,  keeping  the  saw  parallel  to 
the  articular  surface.  With  forceps  trim  the  sharp 
edges  of  the  bone.  When  removing  the  lower  end 
of  the  femur  in  young  people,  be  careful  to  locate 
and  avoid  the  epiphyseal  line.  To  bring  this  line  into 
view  it  may  be  necessary  to  shave  away  a  thin  slice 
from  the  side  of  the  inner  or  outer  condyle.  Examine 
the  raw  surfaces  of  the  bone.  If  disease  is  found 
remove  it  with  the  sharp  spoon  or  chisel.  Review 
the  whole  wound  territory  and  remove  any  remnants 
tf  disease.  Clean,  preferably  by  dissection,  all  fis- 
oulous  tracts.  Close  the  wound  with  or  without  drain- 
age. Treat  as  a  fracture.  Voluminous  dressings  are 
necessary.  Apply  a  long  posterior  splint.  Put  the 
patient  in  bed  with  the  limb  elevated  to  an  almost  vertical  position.  This 
position  is  retained  for  at  least  twenty-four  hours. 

The  other  methods  of  arthrectomy  and  excision  may  be  treated  shortly  as 
they  differ  from  the  above  mostly  in  the  manner  in  which  the  joint  cavity  is 
exposed. 

Method  A  has  been  described  very  fully  merely  as  a  matter  of  convenience 
not  because  of  superiority  over  the  other  procedures  about  to  be  considered. 
Method  B. — Volkmann's  Transverse  Incision. — From  one  epicondyle 
to  the  other  make  an  incision  which  passes  over  the  middle  of  the  patella  (Fig. 
1085).  The  cut  is  made  to  the  bone  throughout  its  whole  course,  and  opens  the 
joint.  Saw  through  the  patella  transversely.  With  sharp  retractors  pull  the 
lower  fragment  of  the  patella  forwards  and  downwards,  thus  exposing  the  syno- 
vialis  lining  the  anterior  wall  of  the  lower  pouch  of  the  joint.     With  forceps, 


Fig.  1085. 


ARTHRECTOMY. 


917 


scissors,  and  knife  dissect  the  above-mentioned  portion  of  synovial  is  from  its 
connections  until  the  semilunar  cartilages  are  reached.  Remove  the  semilunar 
cartilages  and  synovialis  together.  Divide  the  lateral  and  crucial  ligaments. 
Flex  the  knee  until  the  back  of  the  calf  lies  in  contact  with  the  thigh  and  pull  the 
leg  downwards.  By  this  manoeuvre  the  joint  is  made  to  gape  widely  and  the 
posterior  portion  of  the  capsule,  viz.,  that  opposite  the  popliteal  space,  is  made 
freely  accessible  (Fig.  1086).  Dissect  away  the  posterior  synovialis.  Remember 
the  location  of  the  popliteal  vessels  and  nerves. 


Fig.  1086. 


With  sharp  retractors  pull  the  upper  fragment  of  the  patella  forwards  and 
upwards  and  dissect  away  the  synovialis  of  the  upper  pouch  in  the  same  manner 
as  was  done  with  the  lower.  The  deep  fascia  of  the  thigh  may  prevent  the 
necessary  elevation  of  the  flap  containing  the  patella;  if  this  is  so  make  a  longi- 
tudinal incision  through  the  fascia  on  each  side  of  the  patella,  without  cutting 
the  skin. 

Excise  the  articular  ends  of  the  bones  as  already  described.  When  closing 
the  wound  it  is  necessary  to  unite  the  divided  patella  by  means  of  sutures,  pre- 
ferably of  catgut  (chromicized  or  iodized). 


91 8  KNEE-JOINT. 

Method  C. — Make  a  U-shaped  incision  from  one  epicondyle  to  the  other, 
the  convexity  of  the  incision  corresponding  to  the  insertion  of  the  ligamentum 
patellas.  The  incision  only  involves  the  skin  and  subcutaneous  tissues.  Reflect 
the  U-shaped  skin  flap  upwards.  This  exposes  the  patella  and  part  of  the 
capsule  of  the  joint.  Make  a  transverse  incision  through  the  fascia  covering 
the  patella.  Bisect  the  patella  transversely  with  a  saw.  Divide  the  articular 
capsule  on  each  side  of  the  patella.     Proceed  as  in  Method  B. 

Method  D. — This  method  is  the  same  as  C  except  that  the  convexity  of 
the  skin  flap  is  upwards. 

Method  E. — Beginning  at  the  posterior  part  of  one  femoral  condyle  make 
a  curved  incision  which  ends  at  a  corresponding  point  on  the  other  side  of  the 
knee.  The  lowest  point  reached  by  the  curved  incision  is  in  the  middle  line 
at  the  insertion  of  the  ligamentum  patellae.  The  cut  reaches  to  the  bone  through- 
out its  whole  length.  The  flap  thus  outlined  contains  the  patella  and  must  be 
reflected  upwards.  The  rest  of  the  operation  is  to  be  carried  out  on  the  lines 
laid  down  in  describing  Method  B. 

Method  F. — This  method  is  the  same  as  Method  E,  except  that  the  con- 
vexity of  the  curve  is  directed  upwards  and  the  quadriceps  tendon  is  divided 
instead  of  the  ligamentum  patellae. 

Remarks  on  Arthrectomy  and  Excision. — Use  of  Tourniquet  or 
Elastic  Constrictor. — A  few  surgeons  prefer  to  omit  the  use  of  the  elastic 
constrictor,  but  the  vast  majority  find  it  not  only  harmless,  but  most  useful. 

Konig's  plan  is  adopted  by  most  surgeons;  the  constrictor  not  being  loosened 
until  after  the  patient  has  been  returned  to  bed  and  his  leg  fixed  in  a  more  or 
less  vertical  position. 

Drainage. — Most  surgeons  provide  for  drainage  by  means  of  tubes,  rubber 
tissue,  cigarettes,  or  silkworm-gut.  Rutherford  Morison  closes  the  wound 
without  drainage  even  when  hemostasis  is  only  attended  to  by  posture  as  noted 
above. 

Approximation  of  the  Sawn  Ends  of  the  Bones. — Many  means  have 
been  used  to  maintain  apposition  of  the  bones:  bone  pegs,  screws,  removable 
pins,  wire,  suture,  etc.,  etc.  All  are  unnecessary.  If  the  bones  are  placed  in 
apposition  and  kept  at  rest  by  means  of  a  splint  nothing  further  is  required. 

Treatment  of  the  Patella. — After  arthrectomy  the  patella  is  always  care- 
fully preserved;  after  excision  of  the  joint  it  has  frequently  been  removed. 
To  the  author  it  appears  that  it  ought  to  be  preserved  unless  it  is  the  site  of  too 
much  disease  to  permit  of  conservative  treatment. 

How  much  Bone  Ought  to  be  Removed  when  Excision  is  Practised? — 
(a)  The  femur.  Never  injure  the  epiphyseal  line  in  the  young.  Remove  as 
little  of  the  bone  as  possible,  just  enough  to  provide  a  good  raw  surface  for 
union  with  the  tibia.  Remember  that  the  line  of  section  need  not  be  above 
the  highest  point  of  the  disease  (tuberculosis),  the  foci  of  disease  may  be  removed 
with  spoon  and  chisel.  As  a  rule,  less  of  the  tibia  is  removed  than  of  the  femur. 
From  the  patella  only  remove  diseased  tissue. 


INDICATIONS.  919 

In  performing  arthrectomy  in  children  many  surgeons  remove  the  articular 
and  patellar  cartilage  with  a  knife  till  raw  bony  surfaces  are  exposed.  This 
gives  good  bony  anchylosis. 

Indications  for  Operations  in  Tuberculosis  of  the  Knee. — The  tendency 
of  tuberculosis  is  towards  cure.  This  must  be  remembered  by  the  ambitious 
young  operator.  General  supportive  treatment,  especially  a  generous  supply 
of  proper  food  and  a  life  in  the  open  air  in  proper  surroundings  explain  why 
it  is  easier  to  get  good  results  in  the  rich  than  in  the  poor. 

WTien  tuberculous  disease  is  associated  with  much  effusion  into  the  knee, 
evacuation  of  the  fluid  and  injection  of  various  liquids,  e.  g.,  iodoform  emulsion, 
are  beneficial  when  combined  with  other  conservative  treatment.  When 
tuberculous  abscesses  (cold  abscesses)  exist  in  connection  with  a  joint,  but  if 
the  joint  functions  are  still  fairly  well  preserved,  treat  the  abscess  as  an  indepen- 
dent lesion,  by  evacuation  and  injection  or  by  excising  its  lining  membrane  and 
closing  the  wound  without  drainage.  At  the  same  time  treat  the  joint  conser- 
vatively.    Secondary  (pyogenic)  infection  calls  for  radical  treatment. 

If  the  functions  of  a  joint  are  irreparably  lost  the  sooner  excision  of  the  tuber- 
culous synovial  membrane  and  other  diseased  parts  is  performed,  the  better. 
"The  best  test  of  the  amount  of  damage  done  to  the  joint  is  the  extent  of  its 
mobility  imder  an  anaesthetic.  A  creaking  stiff  joint  with  only  slight  mobility 
under  anaesthesia  should  be  excised"  (Morison). 

Any  method  of  operating  is  good  which  fills  the  following  requirements: 
Free  access  to  the  joint.  Ready  removal  of  all  diseased  tissues,  with  the  mini- 
mum destruction  of  healthy  structures,  and  the  reconstruction  of  a  sturdy 
useful  limb  with  an  anchylosed  knee  and  as  little  shortening  as  possible. 

Operation  is  far  more  rarely  indicated  in  children  than  in  adxilts.  In  adults 
belonging  to  the  poorer  classes  operation  may  be  required  to  save  time  and  ex- 
pense, although  the  disease  might  well  be  considered  curable  by  conservative 
means. 

Absolutely  typical  excisions  are  rarely  proper.  The  true  surgeon,  in  suitable 
cases,  explores,  removes  the  disease,  and  repairs  the  parts  in  the  manner  best 
calculated  to  give  a  useful  limb. 

At  present  anchylosis  is  almost  always  to  be  sought  for,  but  the  work  of 
Murphy  and  others  on  the  interposition  of  fat,  etc.,  between  the  joint  surfaces, 
leads  to  the  hope  that  even  after  excision  of  the  knee  for  tuberculosis  a  good 
movable  joint  may  be  obtained. 

Arthritis  Deformans. — W.  Miiller  ("Archiv.  fur  klin.  Chir.,  xlvii,  H.i) 
advocates  operative  interference  in  certain  cases  of  arthritis  deformans  and 
reports  good  results.  The  operation  consists  in  exposing  the  articular  cavity 
by  lateral  incisions,  excising  all  the  diseased  synovialis,  extracting  all  foreign 
bodies  and  with  a  chisel  shaving  off  all  bony  excresences.  The  capsular  and 
skin  wounds  are  separately  closed  with  sutures,  drainage  provided,  immovable 
dressings  applied  and  rest  maintained.  Passive  motion  is  begun  as  early  as  the 
third   week.     The   after-treatment   consists   of   massage   and   of   movements 


920 


KNEE-JOINT. 


(sometimes  under  anaesthesia)  patiently  carried  out.  Active  motion  is  begun 
as  early  as  possible. 

Rutherford  Morison  has  in  two  cases  obtained  good  results  by  excising  the 
joint. 

In  cases  of  "Creaking  knees"  with  effusion  Robert  Jones  opens  the  joint, 
removes  all  fringes  present  and  closes  the  wound;  if  no  effusion  is  present  he 
does  not  operate. 

In  general  terms  it  may  be  said  that  in  arthritis  deformans  if  there  is  much 
pain  and  disability,  if  conservative  treatment  has  failed  to  give  relief,  arthro- 
tomy  is  indicated  for  exploration,  to  be  followed  by  some  form  of  atypical 
resection  according  to  the  lesions  found. 

Congenital  Dislocation  of  the  Knee. — Hubscher's  Operation. — 
Hiibscher  (von  Salis,  "Deutsche  Zeitschrift   fur    Chir.,"  cxiv,  148)  operated 


Fig.   1087. — {Hiibscher.)        Fig.   1088. — {Hiibscher.)       Fig.  1089. — {Hiibscher.) 

on  a  case  of  anterior  dislocation  of  the  tibia  on  the  femur  in  a  girl  fourteen 
months  of  age.  The  patella  was  absent.  Manual  reduction  was  impossible. 
The  skin  was  reflected  in  a  flap  from  in  front  of  the  knee  (Fig.  1087).  The 
tendo  patellae  was  found  to  be  short  and  to  constitute  an  impediment  to  reduc- 
tion. The  tendon  was  incised  longitudinally  down  to  its  insertion  into  the  tibia 
(Fig.  1088).  A  portion  of  the  tibia  corresponding  to  the  insertion  of  one-half 
of  the  tendo  patellae  was  separated  from  the  rest  of  the  bone.  The  other  half 
of  the  tendon  was  divided  transversely  high  up.  Only  after  division  of  the 
anterior  capsule  of  the  knee  was  complete  reducton  possible.  The  two  halves 
of  the  patellar  ligament  were  united  in  such  a  manner  that  the  fragment  of 
tibia  attached  to  one  of  them  lay  in  the  normal  position  of  a  patella  (Fig.  1089). 
The  wound  was  closed.  The  knee  was  immobilized  in  a  position  of  slight 
flexion.     The  result  was  good. 


CHAPTER  LXXXIV. 

PATELLA.     TUBERCULOSIS. 

In  cases  of  primary  tuberculosis  of  the  patella  when  the  focus  of  disease 
is  small  Murphy  advises  the  removal  of  the  diseased  focus,  the  filling  of  the 
resulting  cavity  with  Mosetig's  iodoform  plug  or  wi.h  his  own  glycero-gelat  n- 
formalin  plug.     [Murphy's  plug  is  made  as  follows:     Boil  loo  c.  c.  white  gelatin 


Fig.  1090. — {Murphy.) 

in  150  c.  c.  glycerine  and  500  c.  c.  water.  Add  i  to  2  per  cent,  of  commercial 
formalin]  In  advanced  cases  which  do  not  involve  the  whole  patella  preserve 
the  cartilage  between  the  patella  and  the  joint  for  fear  of  infecting  the  joint. 
The  cases  suitable  for  the  above  treatment  are  rare  and  more  rarely,  still,  will  a 

921 


922 


KNEE-JOINT. 


Fig.  1091. — {Murphy.) 


Fig.  1092. — {Murphy.) 


MURPHY  S    METHOD.  923 

sufficiently  accurate  diagnosi  be  made,  as  the  operation  should  be  carried 
out  without  direct  inspection  of  the  joint  cavity. 

When  the  patella  is  irreparably  diseased  but  the  knee-joint  has  escaped 
tuberculous  involvement,  excision  of  the  patella  is  proper.  In  such  cases  the 
knee  will  have  suffered  from  acute  synovitis,  due  to  the  proximity  of  the  tuber- 
culous foci. 

Murphy's  Method  of  Excising  the  Patella. — Preliminary  Treatment. — 
Before  almost  all  operations  on  the  knee-joint  (fractures  of  patella,  misplaced 
cartilages,  etc.)  Murphy  produces  a  chemical  or  simple  arthritis  and  only 
operates  after  the  patient  has  recovered  from  this.  He  believes  that  the 
cured  arthritis  produces  a  local  immunity  to  infection  and  traumatic  irritation. 
If  this  idea  is  correct,  and  Murphy  has  a  habit  of  being  correct,  the  preliminary 
treatment  is  important. 

Twenty-four  hours  pHor  to  use,  prepare  a  2  to  5  per  cent,  solution  of  formalin 
in  glycerine.  Inject  2  to  6  drams  of  the  solution  into  the  joint  a  week  or  ten 
days  before  operation. 

The  Operation. — Step  i. — Open  the  knee-joint  by  a  7-inch  incision  on  the 
outer  side  of  the  patella  (Fig.  1090),  ("Surg.,  Gyn.,Obst.," March,  1908, p.  266). 

Step  2. — Make  a  subaponeurotic  excision  of  the  patella,  leaving  the  cut 
ends  of  the  quadriceps  tendon  and  tendo  patellae  exposed. 

Step  3. — Reflect  downwards  a  flap  (A  B  C  D)  (Fig.  109 1,)  consisting 
of  portions  of  the  quadriceps  tendon  and  vastus  externus  muscle.  The  flap 
must  be  long  enough  to  easily  reach  the  cut  end  of  the  tendo  patellae.  Stitch 
the  end  B  C  of  the  flap  to  the  ligamentum  patellae  either  in  the  end-to-end  or 
overlapping  fashion.     Close  with  sutures  the  defect  A  E  F  D. 

Step  4. — Suture  the  aponeurosis  of  the  patella  securely  to  the  divided  edge 
of  the  flap  (Fig.  1092). 

Step  5. — Close  the  skin  wound,  after  providing  for  drainage.  Apply  dress- 
ings and  a  straight  posterior  splint. 

It  was  shown  long  ago  by  Wharton  Hood  that  the  patella  is  by  no  means 
essential  to  good  f  uncton  of  the  knee,  hence  the  above  operation  does  not  produce 
so  much  disability  as  might  be  suspected. 


CHAPTER  LXXXV. 
OSTEOTOMY  FOR  BONY  ANCHYLOSIS  OF  THE  KNEE. 

When  tuberculosis  is. the  cause  of  the  bony  anchylosis  it  is  wise  to  operate 
as  far  as  possible  from  the  joint  lest  encapsulated  infective  agents  be  let  loose. 
Operation  is  indicated  when  malposition  interferes  seriously  with  walking  or 
standing.  Whichever  method  of  operating  on  the  anchylosed  bones  is  chosen, 
contracture  of  the  ham-string  muscles  may  interfere  with  correction.  Under 
such  circumstances  tenotomy,  tendon  lengthening,  or  perhaps  transplantation 
of  the  ham-strings  into  the  quadriceps  tendon  becomes  necessary. 

Rhea  Barton  (1835)  ^^^s  the  first  to  perform  open,  and  Langenbeck  (1852) 
first  to  perform  subcutaneous  osteotomy  for  knee  anchylosis.  Gurdon  Buck 
excised  an  anchoylosed  knee   (essentially  a  cuneiform  osteotomy)   in   1844. 

I.  Linear  Osteotomy  of  the  Femur. — On  either  the  inner  or  outer  side  of 
the  rectus  tendon  "on  a  level  with  a  line  drawn  transversely,  a  finger's  breadth 
above  the  upper  portion  of  the  external  condyle"  make  a  longitudinal  wound 
sufficient  to  admit  a  Macewen  osteotome.  Proceed  exactly  as  in  supra-con- 
dyloid  osteotomy.     Figures  1093  and  1094  show  the  result  of  this  section. 

IL  Linear  Osteotomy  of  Both  Femur  and  Tibia. — This  operation  is 
suitable  in  cases  where  section  of  the  femur  alone  insufficient.  Divide  the  femur 
as  described  in  the  preceding  paragraphs.  Divide  the  tibia  immediately  below 
the  anterior  tubercle  (see  p.  843).  Figure  1095  shows  the  result  of  the-double 
section.  Instead  of  making  a  linear  osteotomy  of  the  tibia  Werndorff  ("Wiener 
med.  Woch.,"  lix,  No.  23)  excises  a  wedge  of  bone  with  its  base  anterior.  This 
not  only  helps  in  correcting  the  deformity  but  provides  a  fragment  of  bone 
which  he  inserts  into  the  cleft  left  in  the  femur  after  it  has  been  divided  and 
straightened  (Fig.  1094). 

III.  Cuneiform  Osteotomy  of  the  Femur. — Expose  the  femur  as  in  linear 
osteotomy,  but  make  the  incision  through  the  soft  parts  more  generous.  With 
a  chisel  remove  a  segment  of  bone  as  in  figures  1096  and  1097.  This  operation 
is  calculated  to  correct  a  graver  deformity  than  could  the  simple  linear  section. 

IV.  Cuneiform  and  Trapezoidal  Osteotomy  of  the  Anchylosed  Knee. — 
It  is  presumed  that  the  femur,  tibia,  and  patella  are  fused  into  one  bony  mass. 

Step  I. — Apply  an  elastic  constrictor  to  the  thigh.  Expose  the  parts  to  be 
removed  by  a  large  U  flap  having  its  base  directed  upwards  or  downwards. 
(It  does  not  matter  which.) 

Step  2. — With  an  amputating  saw  or  with  a  very  broad  chisel  excise  a  seg- 
ment of  bone.     The  upper  cut  through  the  bone  should  be  nearly  at  a  right 

924 


ANCHYLOSIS. 


925 


angle  to  the  axis  of  the  femur,  the  lower  cut  nearly  at  a  right  angle  to  the  axis 
of  the  tibia  (Fig.  io)8). 

Step  3. — Attend  to  hemostasis.     Place  the  divided  surface  of  bone  in  apposi- 
tion (Fig.  1099).     Close   the  wound   with   sutures   after   providing   drainage. 


Fig.  1093. 


Fig.  1094. 


Fig.  1095. 


Apply  dressings.  Immobilize.  The  divided  ends  of  the  bones  may  be  kept 
in  apposition  by  being  pegged  or  sutured  together  or  merely  by  means  of  the 
immobilizing  splint  or  dressing.  The  great  objection  to  the  above  operation 
is  the  unavoidable  shortening  of  the  limb  (a)  from  the  removal  of  such  a  mass 


Fig.  1096. 


Fig.  1097. 


Fig.  1098. 


of  bone,  (b)  from  injury  to,  or  destruction  of  the  epiphyseal  cartilages  in  the 
young. 

V.  Curvi-cuneiform  Osteotomy. — To  avoid  shortening  inherent  to 
ordinary  cuneiform  osteotomy  of  the  knee  Helferich  ("Archiv.  f  iir  klin.  Chir.," 
xli,  346;  xlvi,  445)  devised  a  curvi-cuneiform  operation. 


926  OSTEOTOMY   FOR   BONY  ANCHYLOSIS    OF   THE    KNEE. 

Step  I. — Apply  an  elastic  constrictor  to  the  thigh.  Expose  the  anterior  and 
lateral  surfaces  of  the  fused  bones  by  a  large  U  flap  or  by  a  transverse  incision 
over  the  most  prominent  part  of  the  deformity.  Reflect  the  periosteum  from 
the  area  of  bone  to  be  attacked. 

Step  2. — Note  the  position  of  the  epiphyseal  line  of  the  femur  so  as  to  avoid 
it.  To  find  the  line  it  may  be  necessary  to  shave  off  a  thin  slice  of  bone  from 
the  outer  or  inner  side  of  the  femur  v^^ith  a  chisel.  This  exploration  does  no 
harm  and  may  do  much  good.  With  a  narrow-bladed  finger-saw  divide  the 
extreme  lower  end  of  the  femur  in  a  curve  corresponding  to  the  antero-posterior 
curve  of  the  condyles  (Fig.  1098). 

Make  a  similar  curvi-linear  section  of  the  upper  end  of  the  tibia.  The 
curve  of  the  tibial  section  need  not  be  so  pronounced  as  that  of  the  femoral. 


Fig.  1099.  Fig.  iioo. 

The  result  of  the  above  is  the  removal  of  a  curved  wedge  of  bone;  all  that  now 
obstructs  correction  is  the  pressure  of  contracture  of  the  ham-strings  and  of 
fascia  (Fig.  iioo). 

Step  3. — Through  short  longitudinal  incisions  on  each  side  of  the  popliteal 
space  divide  the  ham-strings  and  any  obstructing  fascia.  Remember  the 
location  of,  and  avoid  injury  to  the  peroneal  nerve  between  the  biceps  and  the 
gastrocnemius.  Instead  of  carrying  out  a  mere  tenotony,  it  might  be  well  to 
unite  the  divided  ham-strings  to  the  quadriceps  tendon.  Correct  the  deformity 
without  using  too  much  violence.  Helferich  noticed  that  in  some  cases  com- 
plete correction  interfered  with  the  vascular  supply  of  the  leg;  under  these 
circumstances  he  contented  himself  with  partial  correction  at  the  time  of  opera- 
tion, but  gradually  straightened  the  limb  during  the  after-treatment  before 
solidification  had  time  to  take  place. 

Step  4.— -The  divided  bones  tend  to  remain  in  apposition.  Apposition 
may  be  maintained  by  pegs,  bone,  or  periosteal  sutur.es  or  by  splints  outside 
the  dressings.     Provide  for  drainage.     Close  the  wound.     Apply  dressings. 


ARTHROPLASTY.  927 

Immobilize.  Place  the  limb  in  a  position  of  greai  elevation.  Remove  elastic 
constrictor. 

N.  B. — If  desired,  the  elastic  constrictor  may  be  removed  before  the  wound 
is  closed  and  hemostasis  be  effected  by  ligatures.  In  excision  of  the  knee 
the  author  has  found  that  elevation  of  the  limb  has  always  sufficed  for 
hemostasis. 

Anchylosis  of  Patella  to  Femur. — As  an  extreme  rarity  there  may  be 
bony  anchylosis  of  the  patella  to  the  femur  with  complete  integrity  of  the  rest 
of  the  femoral  articular  cartilage.  Immobility  of  course  is  the  result.  Hel- 
ferich  demonstrated  the  technical  possibility  of  correcting  this  disability  by 
division  of  the  anchylosis  and  interposition  of  a  flap  of  muscle.  Cramer, 
without  knowledge  of  Helferich's  suggestion,  made  use  of  the  same  idea  in  a 
suitable  case.     Cramer's  operation  may  be  performed  as  follows: 

Step  I. — Make  a  longitudinal  incision  on  the  inner  side  of  the  patella  of 
length  sufl&cient  to  give  access  to  the  line  of  anchylosis  and  to  the  lower  part 
of  the  vastus  internus. 

Step  2. — With  chisel  and  mallet  separate  the  patella  from  the  femur  along 
the  line  of  anchylosis. 

Step  3. — Mobilize  a  flap,  of  muscle  from  the  vastus  internus,  the  pedicle 
of  the  flap  being  inferior;  tuck  the  muscular  flap  as  smoothly  as  possible  be- 
tween the  separated  bones. 

N.  B. — Instead  of  a  muscular  flap,  one  of  fat  and  fascia,  as  suggested  by 
Murphy,  may  be  used. 

Step  4. — Close  the  wound.  Dress.  Begin  exercises  as  soon  as  the  wound 
is  healed. 

Arthroplasty. — Before  deciding  on  operation  it  is  necessary-  to  note. 

1.  The  character  of  the  anchylosis — whether  fibrous  or  bony  and  whether 
the  joint  cavity  is  or  is  not  obliterated. 

2.  The  condition  of  the  muscles  which  should  move  the  joint.  If  they  are 
insufficient  or  destroyed,  operation  is  evidently  useless. 

3.  The  condition  of  the  periarticular  structures.  If  they  are  soldered 
together  into  a  mass  of  scar  tissue  arthroplasty  is  impossible. 

4.  That  the  disease  causing  the  anchylosis  is  cured. 

5.  The  general  condition  of  the  patient. 

The  principles  on  which  the  operation  of  arthroplasty  depends  for  success 
are  the  following.     (Strict  asepsis  is  assumed). 

1.  Free  exposure  of  the  joint  by  incisions  which  will  do  least  damage. 

2.  Liberation  of  the  anchylosed  surfaces  by  means  of  knife,  scissors  saw, 
chisel  etc. 

3.  In  case  of  bony  anchylosis  it  is  usually  necessary  to  model  the  ends  of 
the  bone  and  to  reduce  their  size.  Payr  recommends  that  this  modeling  be  done 
on  simple  lines  no  attempt  being  made  to  sculpture  the  end  of  the  bone  into 
its  normal  shape. 

4.  Excision  of  all  the  joint  capsule  as  well  as  contracted  bands  of  fibrous 


928  OSTEOTOMY    FOR    BONY   ANCHYLOSIS    OF    THE    KNEE, 

tissue  and  of  ligaments.  Both  Murphy  and  Payr  put  much  emphasis  on  this 
principle  and  it  certainly  is  based  on  common  sense.  Excision  of  ligaments  and 
capsule  not  only  aids  directly  in  obtaining  free  motion  but  indirectly  also  as  it 
means  the  removal  of  the  articular  nerve  endings  and  thus  minimizes  post 
operative  pain  and  permits  earlier  and  infinitely  less  painful  motion.  In  ex- 
cising the  capsule  and  ligaments  vi^here  they  are  inserted  in  the  bone  it  is  wise 
to  shave  away  a  piece  of  the  bone  with  them. 

5.  Prevention  of  recurrence  of  the  anchylosis.  This  is  attempted  by  the 
interposition  of  pedunculated  flaps  of  living  tissue  (fat-fascia;  muscle;  tendon; 
tendon  sheath);   free  (i.  e.,  non-pedunculated)  flaps  or  grafts  of  living  tissue 

(fascia;  synovial  bursse;  cartilage  etc.) ;  grafts 
of  foreign  structures  e.  g.,  hog's  bladder. 

6.  Careful  hemostasis.  Avoidance  of  drain- 
age except  if  necessary  by  aspiration  of  any 
efifused  blood  after  two  of  three  days  (Payr). 
Most  surgeons  use  drainage. 

7.  Careful,  methodical,  persistent  after- 
treatment. 

Payr  ("Munch.  Med.  Woch.,"  Ivii,  No.  37) 
warns  against  brusque  passive  movements  as 
calculated  to  cause  injury  and  especially 
hemorrhage  which  can  easily  jeopardize  the 
result  desired.  The  same  surgeon  frequently 
prevents  pressure  by  the  ends  of  the  bone  on 
the  interposed  tissues  by  using  direct  extension 
by  means  of  Steinmann's  nails. 

As  soon  as  the  skin  wound  has  united 
change  the  position  of  the  joint  frequently. 
Keep  the  muscles  in  tone  by  massage,  hot 
air,  baths,  electricity  etc.  Payr  finds  injec- 
tions of  Fibrolysin,  repeated  every  second  day, 
serviceable. 

Gentle  passive  motion  should  be  begun  at 
once  and  what  is  of  greater  value  active 
motion.  Tendon  transplantation  may  be 
necessary  to  reinforce  weakened  muscles. 
Murphy's  Operation. — Many  researches 
(Ledderhose,  Langemak,  Thorn,  Franz,  etc.)  have  proved  that  ganglia  and 
bursas  are  the  result  of  a  degeneration  of  connective  tissue  and  that  the 
synovialis  of  joints  is  formed  originally  by  identically  the  same  process.  J.  B. 
Murphy,  accepting  these  truths,  applied  them  to  the  operation  of  arthroplasty. 
Applied  to  the  knee-joint,  his  operation  is  as  follows: 

Step  I. — Apply  the  elastic  constrictor  high  up  on  the  thigh.     Make  an  exter- 
nal longitudinal  incision  from  a  point  6  inches  above  to  a  point  3  inches  below 


Fig.   I  loi . — (Murphy 


ARTHROPLASTY. 


929 


the  knee-joint  (Fig.  iioi).  Do  not  incise  the  deep  fascia  except  to  the  extent 
necessary  for  opening  the  joint  for  overcoming  the  anchylosis.  Make  a  4-inch 
vertical  incision  over  the  inner  side  of  the  joint. 

Step  2. — With  scalpel,  chisel,  or  saw,  free  the  patella  from  the  femur.  Do 
not  divide  the  ligamentum  patellae  or  the  quadriceps  tendon. 

Step  3. — Throughly  divide  and  remove  the  lateral  ligaments  of  the  knee. 
Murphy  lays  great  stress  upon  this  step. 

Step  4. — (a)  if  anchylosis  is  fibrous,  break  or  divide  the  adhesions,  (b) 
If  anchylosis  is  bony  divide  the  bone  with  chisel  or  saw  and  shape  the  ends  of 
the  femur  and  tibia  in  such  a  manner  that  the  lower  end  of  the  femur  is  convex 
and  the  upper  end  of  the  tibia  is  concave  from  before  backwards. 

Step  5. — Dissect  a  large  flap  of  fascia  lata  with  a  thin  layer  of  muscle  attached, 
from  the  outer  surface  of  the  vastus  externus  (Fig.  1102).     The  base  or  pedicle 


^ 

^^^ 

J^/fT'iz'^^ 

'^^^KEM 

^^ 

■.^K"=s!^^ 

iBI^fc* 

Fig.  1 102. — {Murphy.) 


of  the  flap  is  below  and  in  front.  The  flap  must  be  long  enough  to  pass  through 
and  project  from  the  inner  side  of  the  joint,  and  large  enough  to  envelop  the 
sawn  surface  of  the  femur.  Pull  the  flap  through  the  joint;  spread  it  over  the 
lower  end  of  the  femur;  fix  it  in  position  by  a  few  catgut  stitches. 

Step  6. — In  a  similar  manner  prepare  a  smaller  flap  of  fascia  and  interpose  it 
between  the  patella  and  the  femur. 

Step  7. — Close  the  wound.  Provide  for  drainage.  Dress.  Immobilize  in 
the  extended  position.  Massage  and  gentle  passive  motion  may  be  begun  after 
the  first  week.  One  patient  operated  on  by  Murphy  has  obtained  good  use  of 
the  knee  without  the  necessity  of  any  supporting  apparatus. 

Davis's  Operation. — In  a  woman  of  23  with  bony  anchylosis  of  the  knee, 
the  result  of  general  articular  rheumatism,  G.  G.  Davis  ("Am.  Journ.  Ortho- 
pedic Surg.,"  iv,  p.  379)  made  use  of  Murphy's  methods  as  follows:  "Two  long 
incisions  were  made  on  the  sides  of  the  joint  and  two  rectangular  flaps  about 
4  inches  long  consisting  of  fat  and  fascia  lata  turned  down.  The  patella  was 
sawn  loose  from  the  femur  horizontally  and  then  a  wedge-shaped  piece  of  bone 
59 


93©  OSTEOTOMY   FOR    BONY  ANCHYLOSIS    OF   THE    KNEE. 

excised,  2  1/2  inches  (6  cm.)  long  on  its  anterior  side  and  i  1/2  inches  (4  cm.) 
long  on  its  posterior  side.  The  end  of  the  femur  was  sawn  slightly  convex  and 
the  end  of  the  tibia  slightly  concave.  One  flap  was  turned  in  under  the  patella 
and  over  the  femur  and  the  other  drawn  transversely  over  the  sawn  surface  of  the 
tibia  and  fixed  by  a  few  catgut  sutures. The  limb  was  put  up  in  an  extended 
position  in  plaster.  Healing  by  primary  union  except  at  drainage-tube  opening 
which  remained  open  perhaps  three  or  four  weeks.  When  healing  was  com- 
plete an  apparatus  consisting  of  two  side  irons  and  a  screw  mechanism  to  limit 
the  movement  of  the  joint  was  applied.  Movement  was  so  free  from  the  start 
that  the  screw  was  discarded  and  she  was  sent  home  on  crutches.  It  is  now  nine 
months  since  the  operation.  The  joint  can  be  readily  extended  straight  and 
flexed  at  a  right  angle.  The  apparatus  is  essential  to  give  stability  to  the 
joint." 

The  author  saw  the  patient  two  years  after  operation.  Aided  by  the  ap- 
paratus, the  patient  walks  well  and    comfortably. 

Payr's  Operation.— Payr's  method  of  operating  is  in  all  essentials  like  that 
of  Murphy  and  Davis.  Occasionally  he  provides  artificial  lateral  ligaments 
of  silk  and  usually  keeps  the  surfaces  of  the  bone  apart  by  weight  and  pully 
traction  exerted  directly  on  the  upper  end  of  the  tibia  by  means  of  nails  screwed 
into  the  bone  (Fig.  897). 

Implantation  of  Animal  Membranes. — Baer  ("Johns  Hopkins 
Bulletin,"  Sept.,  1909)  made  experiments  with  the  implantation  of  Cargile's 
membrane  in  joints  but  found  that  it  was  too  delicate  and  too  soon  absorbed. 
Pig's  bladder  properly  prepared  and  chromicized  to  last  from  thirty  or  forty  days 
is  sufficiently  durable,  pliable  and  tough  to  answer  the  purpose.  The  knee- 
joint  is  opened  by  lateral  incisions,  the  anchylosis  removed  and  the  membrane 
applied  so  as  to  be  adapted  to  the  whole  contour  of  the  joint  and  fixed  in  place 
by  sutures.  "Every  raw  surface  should  be  absolutely  separated  by  it  from  that 
with  which  it  would  normally  come  in  contact." 

Joint  Transplantation  for  Anchylosis  of  Knee. — E.  Lexer  ("Archiv. 
fiir  klin.  Chir.,"  Ixxxvi,  952)  in  1908  described  two  cases  in  which  he  trans- 
planted the  entire  knee-joint.  The  following  is  a  very  free  translation  of 
Lexer's  description.  "  One  of  these  two  cases  was  submitted  to  operation  seven, 
the  other  four  months  ago.  In  both  there  was  synostosis  with  marked  flexion, 
due,  respectively,  to  suppuration  and  to  tuberculosis.  To  expose  the  joint  I 
formed  a  large  flap  in  front,  having  its  convex  lower  end  at  the  level  of  the  tuber- 
osity of  the  tibia,  so  as  to  permit  reflection  of  the  remnants  of  the  ligamentum 
patellae  and  of  the  articular  capsule  with  the  flap.  Only  in  the  first  case  was 
the  ligament  present,  while  in  both  the  capsule  was  destroyed.  After  exposing 
the  synostosis  in  front,  the  soft  parts,  including  the  tendon  insertions,  were 
separated  from  the  bones,  both  laterally  and  posteriorly,  by  sharp  and  blunt 
dissection.  The  sclerosed  periosteum  remained  attached  to  the  bone.  The 
anchylosed  joint  was  now  excised  in  such  a  manner  as  to  aid  in  reestablishing 
good  position.     In  each  case  the  defect  left  between  the  femur  and  tibia,  when 


perkin's  operation.  931 

the  limb  was  straightened,  was  about  three  fingers'  breadth  in  extent.  The 
knee  was  now  excised  from  a  freshly  amputated  limb.  The  portion  used  for 
transplantation  consisted  of  the  entire  articular  surfaces  and  about  i  1/2  fingers' 
breadth  of  bone  belonging  to  the  femoral  and  tibial  epiphyses.  In  both  cases 
the  crucial  ligaments  were  intact,  in  the  first  case  the  semilunar  cartilages  were 
removed  while  in  the  second  case  these  were  retained  as  were  also  the  lateral 
insertions  of  the  capsule.  WTien  the  implant  was  placed  in  position  it  was 
fixed  to  the  tibia  and  femur  by  means  of  nails  or  wire. 

"The  ligamentum  patellae,  preserved  in  one  case,  was  sutured  to  the  peri- 
osteum. Healing  took  place  in  both  cases.  In  the  first  case  passive  motion 
was  impossible  because  the  patella  had  been  merely  reflected  and  replaced  at 
the  operation  without  having  its  under  surface  protected  by  interposed  material, 
and  so  it  became  adherent.  Three  months  later  the  patella  was  excised." 
During  this  second  operation  the  implant  was  inspected  and  proved  to  be  solidly 
in  place  and  alive.  Both  patients  have  a  small  degree  of  motion  (in  one  passive 
flexion  to  about  45°)  and  pain  neither  on  walking,  nor  standing.  There  is  not 
lateral  motion. 

Remarks. — On  reading  Lexer's  most  delightful  and  brilliant  article  one  is 
reminded  of  the  famous  recipe  for  making  hare  soup,  which  began  with  the  words 
"  first  catch  your  hare."  It  is  only  fair  to  state  that  in  Lexer's  clinic  there  seems 
to  be  a  large  number  of  cases  of  senile  gangrene  without  phlegnon  and  it  is  from 
that  source  that  he  obtains  his  material  for  implantation. 

Juxta-  or  Supra-articular  Osteotomy, — Perkins's  Operation. — This 
operation,  devised  and  carried  out  by  J.  W.  Perkins,  is  applicable  to  similar 
conditions  in  various  articulations,  but  is  perhaps  peculiarly  appropriate  in  the 
knee.  The  principles  of  the  operation  are:  (a)  avoidance  of  injury  to  the  articular 
structures  and,  in  the  young,  to  the  epiphyseal  line,  (b)  Avoidance  of  injury 
to,  or  undue  stretching  of  the  great  vessels  and  nerves  of  the  popliteal  space, 
(c)  Rectification  of  deformity  with  retention  of  any  power  of  movement  which 
the  joint  may  possess. 

The  operation  is  an  extension  of  the  basal  principles  of  Macewen's  supra- 
condyloid  osteotomy. 

Example  1 . — The  knee  is  in  a  position  of  flexion ;  a  moderate  degree  of  further 
flexion  is  possible  but  no  further  extension.  The  structures  (ligaments,  tendons, 
vessels,  etc.)  posterior  to  the  knee  are  contracted. 

The  Operation. — Step  i. — Make  a  longitudinal  incision  2  1/2  to  3  inches 
in  length  down  to  the  bone  on  the  inner  side  of  the  thigh.  The  lower  end 
of  this  incision  should  be  about  1/4  inch  above  the  epiphyseal  line.  If 
necessary,  make  a  similar  incision  on  the  outer  side  of  the  thigh. 

Step  2. — Separate  the  periosteum  from  the  bone  and  retract  the  soft  parts  and 
periosteum  together  so  as  to  expose  a  sufficient  area  of  bone. 

Step  3. — With  osteotome,  chisel,  or  saw  excise  the  rhomboid  of  bone  ab,  cd 
(Fig.  1 103) .  The  segment  of  bone  removed  must  be  sufficient  to  permit  the  limb 
to  be  straightened.     The  short  side  of  the  rhomboid  (ac)  must  be  long  enough 


932 


OSTEOTOMY   FOR    BONY  ANCHYLOSIS    OF   THE    KNEE. 


SO  that  when  the  limb  is  straight  the  structures  behind  the  knee  are  not  unduly 
stretched. 

Step  4. — Straighten  the  limb  (Fig.  1104).  Close  the  wound  with  or  without 
drainage.     Treat  as  a  fracture. 

Example  2. — Genu  Recurvatum. — The  knee  is  in  a  position  of  hyperex- 
tension  (dorsal  flexion).  Further  extension  (dorsal  flexion)  is  possible,  but 
only  adds  to  the  deformity  and  disability.  Operate  as  in  Example  i,  but  make 
the  base  of  the  rhomboid  posterior  instead  of  anterior  (Fig.  1105).  Remove  so 
much  bone  that  when  the  divided  ends  of  bone  are  put  in  apposition  the  whole 
limb  is  straight  while  the  knee-joint  is  in  its  position  of  greatest  hyperextension 
(Fig.  1 106).     Shortening  of  the  flexor  tendons  of  the  knee  may  be  necessary. 


Fig.  1103. 


Fig.  1 104. 


Fig.  1105. 


Fig.  1 106. 


Wreden's  Operation.— ("Russki  Wratsch.,"  1910,  No.  6.,  Ref.  "Zen- 
tralblatt  fiir  Chir.,''  1910,  No.  22.)  Occasionally  some  motion  remains  in  a 
knee  which  has  recovered  from  tuberculous  disease  but  is  in  a  position  of 
flexion.     In  these  cases  Wreden's  operation  may  be  used. 

Through  an  appropriate  incision  (Wreden  uses  a  Y-shaped  incision) 
expose  but  do  not  open  the  upper  synovial  pouch  of  the  knee.  Reflect  down- 
wards the  synovial  pouch  along  with  the  periosteum  of  the  femur.  Divide  the 
femur  transversely  close  to  the  knee;  make  the  lower  end  of  the  shaft  of  the 
femur  protrude  from  the  wound  and  with  a  saw  "sharpen"  the  end  of  the  bone 
like  a  lead  pencil.  In  the  sawn  surface  of  the  epiphysis  construct  a  hole  suitable 
to  receive  the  pointed  end  of  the  diaphysis.  Push  the  end  of  the  diaphysis, 
like  a  peg,  into  the  hole  in  the  epiphysis  after  straightening  the  limb.  The 
principle  of  the  operation  is  the  same  as  that  of  Perkin's  method. 


CH.^PTER    LXXXVI. 
DISLOCATION  OF  THE  PATELLA. 

Recent  outward  dislocation  of  the  patella  may  be  irreducible  without 
operation  when  the  ligamentum  patellae  becomes  caught  under  the  external 
condyle  of  the  femur  or  when  there  is  such  rotation  of  the  patella  on  its  long 
axis  that  its  cartilaginous  surface  faces  forwards.  A  longitudinal  incision  made 
to  the  inner  side  of  the  patella  permits  of  reduction  and  at  the  same  time  gives 
an  opportunity  to  suture  the  torn  inner  capsule  and  any  fibres  of  the  vastus 
internus  which  may  be  ruptured. 

In  old  unreduced  patellar  dislocations  there  is  always  lateral  elongation  of 
the  capsule  on  one  side  of  the  bone  and  there  may  be  cicatricial  contraction  on 
the  other  side.  (The  dislocation  is  almost  always  outwards,  hence  the  elonga- 
tion of  the  capsule  is  on  the  inner  side.)  If  disability  is  marked,  operation  is 
demanded. 

Make  an  incision  to  the  inner  side  of  the  patella  and  open  the  joint.  If 
possible  reduce  the  dislocation  and  shorten  the  elongated  capsule  laterally 
either  by  excising  an  elliptical  segment  and  closing  the  wound  by  sutures  or 
by  closing  the  orginal  longitudinal  wound  in  such  a  fashion  as  to  make  one 
edge  of  the  wound  overlap  the  other.  If  contraction  of  the  outer  portion  of  the 
capsule  renders  reduction  by  simple  arthrotomy  impossible,  a  longitudinal 
incision  may  be  made  through  the  contracture.  Access  to  the  portion  of  cap- 
sule at  fault  may  be  obtained  according  to  circumstances,  (a)  through  the 
original  wound,  through  the  joint  cavity,  under  the  patella;  the  capsular  divi- 
sion being  made  from  within  outwards;  (b)  through  the  original  wound  by  dis- 
secting the  skin  from  over  the  patella,  retracting  the  skin  and  cutting  the  capsule 
from  without  inwards;  (c)  through  a  special  incision. 

If  hemostasis  is  complete  close  the  wound  without  drainage;  otherwise  insert 
a  drain  of  rubber  tissue  or  oil-silk  for  about  twenty-four  hours.  Dress.  Im- 
mobilize in  a  semi-flexed  position  until  the  wound  has  healed.  After  two  weeks 
begin  massage  and  passive  motion.  Walking  may  usually  be  begun  in  about 
five  weeks. 

Recurrent  or  Habitual  Dislocation  of  the  Patella. — When  orthopedic 
apparatus  proves  inefficient  or  inconvenient,  operation  is  indicated. 

The  principal  conditions  favoring  the  occurrence  of  habitual  dislocation 
(Hildebrand)  are  the  following: 

1.  External  condyle  absolutely  or  relatively  less  prominent  than  internal 
condyle. 

2.  Patellar  fossa  too  small. 

3.  Genu  valgum. 

4.  Abnormal  external  rotation  of  the  lower  leg. 

933 


934 


DISLOCATION    OF    THE    PATELLA. 


5.  Abnormal  laxness  of  the  quadriceps  femoris  or  of  the  ligamentum  patelte. 

6.  Injuries  of  the  capsule,  tears  of  the  capsule,  or  of  the  vastus  internus 
or  its  tendon  which  have  healed  and  stretched. 

7.  Stretching  of  the  capsule  in  genu  valgum,  e.  g.,  occasioned  by  hydrops, 
etc.  A  longitudinal  incision  along  the  inner  side  of  the  patella  down  to,  but 
not  through  the  joint  capsule  permits  examination  as  to  its  laxity.  If  laxity 
of  the  capsule  is  the  main  lesion,  it  is  easy  (a)  to  excise  an  ellipse  from  it  and 
close  the  wound  with  sutures,  (b)  to  incise  the  capsule  and  close  the  wound  in 
such  a  fashion  that  one  edge  overlaps  the  other,  or  (c)  to  catch  the  unopened 
capsule  in  forceps,  throw  it  into  folds  and  fix  these  folds  with  sutures. 

If  the  dislocation  is  due  to  improperly  united  tears  of  the  vastus  internus 
and  its  tendon,  the  same  longitudinal  incision  exposes  such  and  they  may  be 
so  repaired  that  the  muscle  can  once  more  act  properly  on  the  patella.  Trau- 
matic hydrops  may  cause  habitual  dislocation  in  a  knock-kneed  subject. 
Osteotomy  correcting  the  knock-knee  has  cured  the  dislocation  (Hildebrand). 
Hildebrand  reports  a  case  in  which  there  was  a  flattening  of  the  external  con- 
dyle but  no  knock-knee;  when  the  knee  was  extended  there  was  incomplete 
luxation,  but  in  flexion  the  luxation  disappeared.  The  tuberosity  of  the  tibia 
was  transplanted  inwards;  the  result  was  excellent. 

The  above  hints  show  that  in  habitual  dislocation  of  the  patella  the  surgeon 
must  not  be  governed  by  hard  and  fast  rules,  but  must 
as  far  as  possible  be  guided  in  his  treatment  by  a  study 
of  causation. 

Goldthwaite's  Operation. — In  uncomplicated  cases 
of  recurring  dislocation  of  the  patella  Goldthwaite's 
operation,  either  alone  or  plus  capsularrhaphy,  is  ex- 
cellent. 

Step  I. — Expose  the  ten  do  patellae  freely  through  a 
longitudinal  incision. 

Step  2. — Split  the  tendon  longitudinally.      Divide  the 

inner  half  of  the  tendon  transversely  at  its  insertion  into 

the  tibia  thus  forming  a  tendon  flap  which  has  its  base 

above  at  the  patella. 

Step  3. — With  closed  scissors  or  forceps  burrow  under  the  inner  (intact) 

half  of  the  patellar  tendon,  pull  the  mobilized  flap  of  tendon  through  this 

tunnel  and  unite  it  by  sutures  to  the  periosteum  and  to  the  expansion  of  the 

tendon  of  the  sartorius  muscles  (Fig.  1107). 

Wullstein's  Operation. — In  a  severe  case  of  external  congenital  dislocation 
of  the  patella  WuUstein  (" Zentralblatt  fur  Chir.,"  1906,  No.  38)  found  that 
the  inner  portion  of  the  joint  capsule  was  excessive  in  quantity  while  the  outer 
was  correspondingly  narrow.     He  operated  as  follows: 

Step  I. — By  means  of  a  horseshoe-shaped  incision  reflect  upwards  a  very 
large  flap  of  skin  from  over  the  knee-joint  and  thus  expose  the  anterior  and 
most  of  the  lateral  aspects  of  the  joint  as  well  as  the  ligamentum  patellae  to 


Fig.  1107, 


WULLSTEIN  S    OPERATION. 


935 


below  the  tibial  tuberosity  and  the  quadriceps  tendon  to  a  point  above  the 
superior  recess  of  the  synovialis. 

Step  2. — By  blunt  dissection  separate  the  quadriceps  tendon  and  the  liga- 
mentum  patellae  from  the  underlying  portion  of  the  joint  capsule. 

Step  3. — To  the  outer  side  of,  and  about  1/4  inch  from  the  patella  incise  the 
capsule  (both  fibrous  and  synovial)  along  the  line  cd  (Fig.  1109).  Make  the 
corresponding  incision  A  B  (Figs.  1 108  and  1 109)  on  the  inner  side  of  the  patella. 
Retract,  and  elevate  the  quadriceps  muscle  and  tendon  from  the  upper  recess 
of  the  synovialis  and  continue  the  incision  A  B  andC  D  upwards  to  meet  at  the 
point  E  corresponding  to  the  highest  part  of  the  joint  cavity.  Elevate  or  retract 
the  ligamentum  patellae  and  continue  the  incisions  A  B  and  C  D  downwards  to 
meet  at  the  point  B. 


Fig.  1 108. — {Wullstein.) 


Fig.   1 109. — -{Wullstein.) 


Step  4. — Push  the  patella  inwards  to  the  extent  necessary  for  correction  of 
the  deformity.  Note  how  much  of  the  inner  portion  of  the  capsule  is  excessive 
and  guided  by  that  information  make  the  incision  X  Y  (Fig.  1108)  parallel 
to  A  B.  Retract  the  vastus  internus  and  continue  the  cut  X  Y  under  the 
vastus  to  the  point  Z. 

Step  5. — The  incisions  F  B  A  E  and  Y  X  Z  from  a  flap  Q  of  joint  capsule 
on  the  inner  side  of  the  joint.  Transfer  the  flap  Q  under  the  patella  from  the 
inner  to  the  outer  side  of  the  joint.  When  the  patella  is  pushed  into  its  correct 
position  the  wound  made  by  the  incision  E  C  D  B  (Fig.  1109)  gapes.  Into  this 
defect  on  the  outer  side  of  the  joint  suture  the  flap  Q. 

Step  6. — Suture  the  capsular  wounds. 

Step  7. — Mobilize  the  sartorius  muscle  and  suture  its  outer  edge  to  the  inner 
edge  of  the  patella.     This  aids  in  keeping  the  patella  in  position 

Step  8. — Close  the  wound.     Dress.     Immobilize. 


CHAPTER  LXXXVII. 


ANKLE. 


Puncture  and  Injections. — Krause  recommends  that  the  trocar  puncture 
the  tissues  vertically  immediately  below  one  or  the  other  malleolus  and  then 
that  its  point  be  directed  upwards.  If  injections  are  necessary  they  may  be 
made  more  definitely  through  an  arthrotomy  incision  than  by  means  of  the 
trocar.  The  material  used  for  injection  varies  (carbolic  solution,  formalin- 
glycerine,  iodoform  in  glycerine,  oil  or  ether,  etc.). 

Arthrotomy. — Step  i. — Make  a  2-inch  vertical  incision  along  the  anterior 
border  of  the  external  malleolus  and  ending  about  1/2  inch  below  the  tip  of 
the  malleolus.  The  extensor  tendons  and  the  peroneus  tertius  lie  to  the  inner 
side  of  the  incision.  Divide  the  annular  ligament.  Open  the  joint  immediately 
in  front  of  the  malleolus. 


Fig.   mo. — (Lahey.) 


Fig.   nil. — (Labey.) 


Step  2. — Pass  a  closed  forceps  through  the  above  incision  across  the  ankle 
to  the  inner  side  of  the  lirhb  (Fig.  mo).  The  forceps  must  be  in  contact  with 
the  bone,  must  pass  through  the  joint  itself  and  so  lie  behind  the  synovial  sheath 
of  the  extensor  tendons.  Make  the  point  of  the  forceps  raise  the  soft  parts 
immediately  in  front  of  the  internal  malleolus.  Divide  the  soft  parts  over  the 
point  of  the  forceps.    With  the  forceps  pull  a  tube  through  the  joint  (Fig.  11 11). 

If  instead  of  draining  the  joint  it  is  desired  to  fill  it  with  iodoform  emulsion 
or  such  like  material,  this  may  be  done  through  the  incision  and  the  wound 
closed  with  sutures. 

Step  3. — If  the  single  or  double  anterior  arthrotomy  wound  is  insufficient 

936 


ARTHRECTOMY. 


937 


for  drainage,  it  is  easy  to  make  a  posterior  counterpuncture  on  the  outer  side 
of  the  tendo  achillis.  If  it  is  necessary  to  incise  on  the  inner  side  of  the  tendo 
achillis,  remember  the  position  of  the  posterior  tibial  vessels  and  nerve  as  well 
as  the  flexor  tendons  of  the  foot  and  avoid  them. 

Excision  of  the  Ankle. — Langenbeck's  Subperiosteal  Resection  of 
the  Ankle. — Lay  the  foot,  inner  side  downwards,  on  a  firm  sand  bag.  On 
the  posterior  margin  of  the  fibula  make  a  longitudinal  incision  i  1/2  to  2  1/2 
inches  in  length,  directly  to  the  bone.  The  lower  end  of  the  cut  is  opposite  the 
tip  of  the  malleolus.  Some  surgeons  prefer  an  I-shaped  incision  on  the  outer 
surface  of  the  fibula  (Fig.  11 12). 

With  periosteal  elevator  separate  the  periosteum  and  soft  parts  together 
from  the  external  and  anterior  surfaces  of  the  bone.  At  the  lower  end  of  the 
malleolus  it  is  necessary  to  supplement  the  blunt  dissection    by  cutting  with 


Fig.  1112. — (Labey.) 


Fig.   1113.- — (Labey. 


scissors  or  knife.  In  cutting,  the  edge  of  the  knife  or  the  point  of  the  scissors 
must  be  directed  against  the  bone  to  avoid  injury  to  the  periosteum  and  soft 
parts.  This  shelling  of  the  soft  parts  from  the  bone  is  carried  forwards  to  the 
synovial  insertion,  which  is  also  separated  from  the  bone. 

In  similar  fashion  clear  the  posterior  surface  of  the  fibula  of  its  coverings 
until  the  interosseous  ligament  is  reached  and  divided.  The  ligament  should 
be  injured  as  little  as  possible.  Choose  the  point  at  which  it  is  desired  to 
divide  the  fibula.  Protect  the  soft  parts  with  a  retractor  or  periosteal  elevator 
and  divide  the  bone  with  a  Gigli  wire  saw  or  chisel  (Fig.  1113).  Seize  the  upper 
end  of  the  sawn  off  portion  of  bone  with  lion  forceps,  pull  it  outwards,  divide 
or  separate  all  adhesions  with  the  elevator,  knife,  or  scissors  and  remove  the 
bone.  Lay  the  foot  on  its  outer  side.  Make  a  vertical  incision  from  the  tip 
of  the  internal  malleolus  upwards  for  2  1/2  inches  along  the  middle  line  of  the 
tibia.  If  desired  one  may  supplement  the  vertical  by  a  transverse  curved 
incision  at  its  lower  end  or  by  a  transverse  incision  at  each  end.  The  periosteum 
is  divided  at  the  same  time  as  the  skin.     With  straight  and  curved  periosteal 


938 


ANKLE. 


elevators  separate  the  periosteum  and  all  structures  superficial  to  it  (tendons, 
vessels,  nerves,  etc.)  from  the  bone.  Divide  the  tibia  w^ith  a  saw  or  chisel 
at  the  same  level,  if  possible,  as  the  fibula.  With  forceps  pull  the  lower  frag- 
ment of  bone  outwards  and  downwards,  at  the  same  time  severing  its  connec- 
tions to  the  interosseous  membrane  and  articular  capsule  with  the  periosteal 
elevator,  knife,  or  scissors.  Remember  always  to  cut  against  the  bone  so  as  to 
avoid  unnecessary  injury.     Remove  the  bone. 


Fig.    1114. 


(Oilier  advises  that  the  bones  should  be  divided  oblicjuely;  the  line  of  section 
being  from  above  and  within,  downwards  and  outwards.  He  states  that  by  so 
proceeding  greater  solidity  of  the  ankle  results.) 

Examine  the  astragalus.  If  it  is  diseased,  but  not  to  a  serious  extent, 
remove  the  diseased  tissues  with  the  sharp  spoon  or  chisel.  With  forceps 
and  scissors  trim  away  ragged  and  loose  pieces  of  cartilage.  If  it  is  necessary 
to  remove  the  whole  superior  portion  of  the  body  of  the  astragalus  this  may  be 
accomplished  with  the  chisel  or  saw.  If  the  saw  is  used  the  soft  parts  must 
be  protected  by  using  suitable  retractors  or  by  holding  them  aside  and  covering 
them  with  periosteal  elevators.  Pack  the  cavity  of  the  wound  with  iodoform 
gauze  leaving  the  incisions  open,  or  partially  close  the  incisions  with  sutures 


KONIG  S    OPER.A.TION. 


939 


and  provide  tubular  drainage.  If  no  secondary  infection  is  present,  the  wound 
cavity  may  be  filled  with  Mosetig's  iodoform  plug  or  some  equivalent  and 
closed  without  drainage.  Dress.  Immobilize  with  plaster  of  Paris.  While 
the  plaster  is  hardening  the  foot  must  be  held  in  a  position  at  right  angles  to 
the  leg  and  neither  everted  nor  inverted.  If  much  shortening  is  expected 
the  foot  may  be  held  in  a  position  of  slight  plantar  tiexion. 

Konig's  Operation. — -Konig's  operation  gives  admirably  free  access  to 
the  ankle-joint  and  is  specially  indicated  in  tuberculous  disease  where  it  is 
important  to  expose,  observe,  and  treat  not  merely  the  ankle  itself  but  the  bones 
and  joints  which  lie  near  it.  From  a  point  on  the  anterior  margin  of  the  tibia 
I  1/2  to  2  1/2  inches  above  the  ankle-joint  and  immediately  internal  to  the 
extensor  tendons  make  an  incision  downwards  and  forwards  over  the  articula- 


FlG.     hi: 


tion,  over  the  mner  side  and  neck  of  the  astragalus  to  end  in  front  of  the  promi- 
nence of  the  scaphoid.  On  the  outer  side  of  the  ankle  make  a  similar  incision 
along  the  anterior  surface  and  margin  of  the  fibula,  across  the  articulation 
and  ending  on  the  outer  side  of  the  cuboid  at  the  level  of  the  astragalo-scaphoid 
joint.  With  forceps,  knife,  and  elevator  separate  the  whole  bridge  of  tissue 
between  the  two  cuts,  from  the  underlying  bones  (Fig.  11 14).  If  the  case  is 
one  of  tuberculosis,  put  the  foot  in  a  position  of  dorsal  flexion,  lift  the  tissue 
bridge  out  of  the  way  with  a  blunt  hook,  examine  the  whole  anterior  articular 
region,  remove,  by  dissection,  the  anterior  synovialis,  and,  if  a  partial  opera- 
tion will  suflSce,  remove  any  diseased  bone  with  chisel  and  spoon.  Konig 
writes:  "If  a  large  focus  is  present  in  the  astragalus  there  is  always  danger 
that  the  three  neighboring  joints  are  affected  and  one  must,  as  a  rule,  remove 
the  astragalus.  The  removal  may  be  effected  through  either  incision,  prefer- 
ably through  the  inner,  by  the  use  of  forceps,  scissors,  and  knife  with  the  assis- 
tance of  strong  periosteal  elevators."      After  the  astragalus  is  removed  a  good 


940  ANKLE. 

view  can  be  had  of  neighboring  structures  and  from  them  diseased  foci,  if 
limited  in  extent,  may  be  removed. 

If  before  the  astragalus  is  removed  it  is  known  that  the  malleoli  ought  to 
be  excised  one  proceeds  as  follows: 

Make  the  incisions  as  already  described  down  to  the  bone,  but  although 
dividing  the  periosteum  do  not  separate  it  from  the  malleoli  (Fig.  1115).  Intro- 
duce a  broad-bladed  chisel  into  the  wound  and  cut  from  the  outer  surface  of 
the  malleoli  a  thin  shell  of  bone.  This  osseous  shell  is  covered  by  its  periosteum 
which  is  continuous  above  with  the  periosteum  of  the  tibia  or  fibula  as  the  case 
may  be  and  below  with  the  lateral  ligament.  Retract  the  shell  of  bone  outwards 
along  with  its  attachments,  divide  the  rest  of  the  bone  transversely  with  the 
chisel,  and  remove  the  fragment.  The  rest  of  the  operation  is  to  be  carried 
out  as  already  described.  By  the  above  procedures  even  the  calcaneal  and 
scaphoid  joints  can  be  reached  and  treated. 

The  active  operation  being  ended,  clean  the  wound  cavity  and  rub  it  with 
iodoform,  provide  drainage  either  with  tubes  or  iodoform  gauze,  partially 
close  the  wound  with  sutures,  press  the  loosened  shells  of  bone  inwards,  and 
apply  dressings.  As  an  alternative,  fill  the  cavity  with  Mosetig's  iodoform 
wax  and  close  without  drainage.  Immobilize  with  plaster  of  Paris  as  in 
Ollier's  operation.  As  anchylosis  is  desired,  the  after-treatment  consists  in 
keeping  the  parts  at  rest  until  they  have  become  firm.  If  sinuses  form  and 
persist  they  must  be  dilated  or  opened  and  their  cause  removed. 

Ochsner's  Method. — Operation. — An  incision  is  carried  directly  across 
the  anterior  surface  of  the  ankle  from  malleolus  to  malleolus  through  the  skin 
superficial  and  deep  fascia  and  the  sheaths  of  all  the  tendons  in  the  course  of 
the  incision.  Externally  the  peroneal  artery  and  nerve  should  be  avoided,  as 
well  as  the  tendons  of  the  peroneal  muscles,  which  can  readily  be  drawn  out 
of  the  way.  Internally  the  posterior  artery  and  nerve  should  be  protected. 
Each  tendon  is  then  lifted  up  in  the  incision  and  transfixed  with  two  fine 
catgut  sutures  from  i  to  2  centimeters  apart.  These  sutures  are  caught  in 
similar  artery  forceps  for  purposes  of  identification,  then  the  tendon  is  cut 
transversely  between  these  sutures  (Fig.  11 16).  After  all  thet  endons  have 
been  disposed  of  in  this  manner,  the  joint  is  opened  by  a  free  transverse  incision 
and  the  sole  of  the  foot  is  forced  back  upon  the  calf  of  the  leg.  In  this  manner 
the  entire  joint  is  opened  freely,  so  that  all  diseased  tissue  can  be  removed. 
After  this  has  been  accomplished,  the  foot  is  placed  in  position,  the  tendons 
are  carefully  adjusted,  which  can  be  done  with  great  ease,  because  the  two 
sutures  upon  two  corresponding  tendon  ends  are  fastened  to  hemostatic 
forceps  of  the  same  pattern.  Each  tendon  is  carefully  sutured  and  a  fine 
stitch  is  placed  in  the  fascia  to  cover  the  line  of  suture  in  the  tendon.  Then 
the  skin  is  sutured  over  all.  If  drainage  seems  necessary,  this  is  applied 
through  and  through,  and  even  in  cases  apparently  requiring  no  drainage,  I 
have  usually  passed  a  few  strands  of  catgut  or  silkworm-gut  entirely  across 
the  foot,  permitting  the  ends  to  protrude  from  the  lower  angles  of  the  wound 


ochsner's  operation. 


941 


Fig.  1 1 16. —{Ochsner.) 


942  ANKLE. 

in  order  to  drain  the  serum  which  may  be  secreted  by  the  large  surface  during 
the  first  few  days.  A  large  dressing  is  applied  and  the  foot  is  immobilized  in 
a  position  at  a  little  less  than  right  angle. 

After-treatment. — The  foot  is  elevated  in  order  to  favor  return  circulation. 
If  drainage  has  been  employed,  this  is  left  in  place  from  one  to  two  weeks. 
The  dressing  is  not  changed,  unless  this  is  indicated  by  the  discharge,  for  a 
week  or  ten  days,  in  order  to  avoid  moving  the  foot,  and  after  that  as  seldom 
as  possible  for  the  same  reason. 

Prognosis. — The  prognosis  is  very  good  after  this  operation.  The  free 
exposure  of  the  surfaces  insures  thoroughness,  and  consequently  the  cure  is 
usually  permanent.  The  anchylosis  of  the  surfaces  immediately  in  the  field 
of  operation  does  not  interfere  with  movement  because  the  tarso-metatarsal 
joint  will  supply  the  motion  necessary.  The  tendons  unite  readily  and  act 
normally.  There  is  no  operation  for  the  relief  of  joint  tuberculosis  that  has 
given  me  more  satisfaction  than  this  one  just  described.  With  this  method 
it  is  possible  often  to  obtain  a  useful  foot  in  cases  which  formerly  could  only  be 
relieved  by  an  amputation   (Ochsner,   "Clinical   Surgery,"  p.   727). 

Remarks. — Arthrotomy  is  indicated  in  cases  of  pyogenic  arthritis  to  provide 
drainage.  It  may  also  be  used  as  a  preliminary  to  filling  the  joint  cavity  with 
iodoform  emulsion.  Arthrectomy  is  rarely  indicated.  The  results  are  not 
usually  very  gratifying  and  amputation  is  usually  the  operation  of  choice  when 
conservative  treatment  and  minor  operations  fail. 


CH.\PTER  LXXXVITI. 
DISLOCATION  OF  THE  ASTRAGALUS. 

Occasionally  the  astragalus  is  dislocated  from  both  its  superior  and  inferior 
connections.  Reduction  always  requires  a  general  anaesthetic,  and  as  failure 
to  reduce  by  manipulation  is  probable,  the  surgeon  ought  to  be  prepared  to 
operate  at  once.  The  bone  so  presses  upon  the  soft  parts  that  gangrene  of 
the  skin  is  sure  to  result,  unless  reduction   is  effected  or  the  bone  excised. 

Make  an  incision  on  the  inner  side  of  the  ankle  from  a  point  i  inch  above 
the  articular  surface,  just  in  front  of  the  malleolus,  downwards  and  forwards  to 
the  internal  cuneiform  bone.  Avoid  injury  to  the  tendon  of  the  tibialis  anticus. 
Separate  and  retract  all  the  soft  parts  covering  the  astragalus.  Endeavor  to 
effect  reduction  by  exerting  traction  on  the  foot  and  pressure  on  the  astragalus. 
If  this  fails  and  if  more  free  access  promises  some  prospect  of  success,  make 
a  corresponding  incision  on  the  outer  side  from  just  above  and  in  front  of  the 
external  malleolus  downwards  and  forwards  to  the  cuboid.  Expose  the  parts 
involved.  Once  more  attempt  reduction.  If  the  attempt  still  fails,  remove 
the  astragalus.  Astragalectomy  gives  such  good  results  that  it  is  foolish  to 
run  much  risk  in  striving  after  the  more  ideal  operation.  If  the  astragalus 
is  completely  separated  from  its  connections  or  nearly  so,  then  its  removal 
must  be  the  rule.  When  the  dislocation  is  complicated  by  fracture  and 
especially  when  it  is  compound  (open)  and  infection  is  probably  present, 
astragalectomy  followed  by  drainage  is  the  procedure  of  choice. 


943 


CHAPTER    LXXXIX. 

SUBASTRAGALOID  DISLOCATION. 

If  manipulation  under  an  anaesthetic  fails,  operation  is  demanded.  Baum- 
gartner  and  Huguier  ("Re\"ue  de  Chir.,"  Aug.,  1907)  divide  the  cases  requiring 
operation  into  two  classes  according  to  whether  the  astragalus  is  or  is  not 
fractured. 

I.  The  Astragalus  is  Not  Fractured. — Reduction  by  arthrotomy  is  the 
operation  of  choice.  Make  an  incision  direcdy  over  the  prominent  head  of 
the  astragalus.  Recognize  the  structures  obstructing  reduction.  If  these 
a:e  ligamentous  bands,  di\'ide  them  in  one  or  more  places  (Quenu);  if  they  are 
displaced  tendons  (e.  g.,  the  tendon  of  the  tibialis  anticus  sometimes  lies  along 
the  inner  and  upper  part  of  the  neck  of  the  astragalus  which  is  then  tightly 
held  between  it  and  the  calcaneo-scaphoid  ligament)  (Stimson)  the  tendons 
may  be  pushed  aside,  or  if  this  is  impossible  they  may  be  diWded  and  reunited 
after  reduction  is  obtained. 

Reduce  the  dislocation  by  minipulation,  especially  by  flexing  the  foot, 
and  by  direct  pressure.  Close  the  wound  with  sutures.  Dress.  Immobilize 
for  about  three  weeks.  If  reduction  by  arthrotomy  fails,  it  is  easy  to  proceed 
to  rfstragalectomy,  either  complete  or  incomplete.  Only  so  much  of  the 
astragalus  ought  to  be  removed  as  will  permit  of  the  foot  being  placed  in  a 
good,  useful  position. 

II.  The  Astragalus  is  Fractured  as  well  as  Dislocated. — (a)  The 
fracture  affects  the  neck  alone.  The  separated  and  dislocated  head  of  the 
bone  may  be  reduced  or  removed  according  to  circumstances. 

(b)  The  body  of  the  bone  is  fractured.  Astragalectomy  is  usually  the  best 
procedure  to  adopt.  In  compound  (open)  dislocation  the  indications  for 
operation  are  much  the  same  as  given  above.  Astragalectomy,  then,  is  indicated 
in  cases  of  subastragaloid  dislocation,  (i)  when  the  luxation  is  irreducible  or 
operative  reduction  has  failed;  (2)  when  infection  is  present;  (3)  in  old  cases. 


944 


CHAPTER  XC. 

OS  CALCIS. 

Exostosis  on  the  Plantar  Surface  of  Os  Calcis. — Exostoses  in  this  posi- 
tion (Figs.  1 1 17,  1 1 18)  are  not  extremely  rare,  but  may  be  disabling  on  account 
of  pain.  Operation  is  demanded  when  relief  is  not  obtained  by  the  use  of  a 
cushioned  heel.     Make  an  incision  along  the  inner  side  of  the  foot  close  to  the 


Fig.   1 117. — {Bradford.) 

sole  and  opposite  the  site  of  exostosis.     By  sharp  and  blunt  dissection  expose 
the  affected  portion  of  os  calcis. 

With  a  chisel  remove  the  bony  spur.     Close  the  wound  with  or  without 
drainage. 


60 


945 


946 


OS   CALCIS. 


Fig.    1112,.— {Bradford.) 


CHAPTER  XCI. 
BUNION. 

HALLUX  VALGUS. 

Hallux  valgus  consists  in  an  inward*  deviation  of  the  great  toe,  the  last 
phalanx  of  which  may  lie  transversely  across  the  second  toe.  The  head  of  the 
metatarsal  bone  is  pushed  outwards,  is  usually  enlarged,  and  part  of  its  articu- 
lating surface  is  no  longer  apposed  to  that  of  the  phalanx.  Between  the  bone 
and  skin  there  is  a  bursa  formed  which  frequently  becomes  inflamed  (bunion). 

Dwight  has  described  a  supernumerary  bone  which  occasionally  exists 
between  the  bases  of  the  first  and  second  metatarsals.  To  this  bone  he  has  given 
the  name  intermetatarseum.  The  intermetatarseum  may  be  free  or  may  be 
fused  with  the  first  or  the  second  metatarsal  or  with  the  internal  cuneiform 
bone.  J.  K.  Young  believes  that  Dwight's  bone  is  the  cause  of  some  forms 
of  hallux  valgus  and  if  detected  by  the  X-rays  in  an  early  case  of  deformity 
its  removal  should  arrest  the  condition  and  relieve  all  symptoms.  Young 
has  performed  the  operation  on  a  case  of  six  years'  duration. 

Barker's  Operation  (Metatarsal  Osteotomy). — Support  the  outer  side 
of  the  foot  on  a  sand-bag. 

Step  I. — Make  an  incision  directly  to  the  bone,  about  one  inch  long,  over 
the  prominence  of  the  metatarsal  head,  on  the  inner  side  of  the  foot. 

Step  2. — With  a  chisel  divide  the  metatarsal  bone  transversely  at  a  point 
about  1/2  inch  from  the  head.  If  the  deformity  is  great  instead  of  simply 
dividing  the  bone,  excise  a  wedge  from  it. 

Step  3. — Straighten  the  toe.     Apply  dressings.     Immobilize. 

Hueter's  Operation  (Metatarso-phalangeal  Arthrectomy). — Step  i. — 
By  manipulation  locate  the  metatarso-phalangeal  joint.  Make  a  longitudinal 
incision  on  the  inner  side  of  the  foot  sufficient  to  expose  the  joint  and  the 
immediately  adjoining  bones. 

Step  2. — With  a  chisel  shave  off  sufficient  of  the  articular  ends  of  the  meta- 
tarus  and  phalanx  until  correction  of  the  deformity  is  easy. 

Step  3. — Close  the  wound.  Apply  dressings.  Immobilize  in  correct 
position. 

Riedl's  Operation. — Osteotomy  of  the  Cuneiform  Bone. — Step  i. — 
Make  a  longitudinal  incision  on  the  inner  side  of  the  foot  sufficient  to  expose 
the  internal  cuneiform  bone  and  its  articulation  with  the  first  metatarsal. 

Step  2. — Avoiding  injury  to  the  insertion  of  the  tibialis  anticus,  cut  a  wedge 
of  bone  from  the  cuneiform.     The  wedge  must  have  its  base  on  the  external 

*The  word  "  inward  "  is  used  in  relation  to  the  middle  line  of  the  foot. 

947 


948 


BUNION. 


(fibular)  side  (Fig.  1119).  The  thickness  of  the  wedge  corresponds  to  the 
amount  of  metatarsal  adduction. 

Step  3. — Through  the  wound  in  the  bone  with  strong  scissors  or  knife 
cut  around  the  external  angle  of  the  base  of  the  first  metatarsal  bone  so  as  to 
mobilize  it. 

Step  4. — Place  the  metatarsal  bone  in  correct  position  (Fig.   1119). 


Fig.  1 1 19. — -{Riedl.) 

Step  5. — Correct  the  position  of  the  great  toe  by  some  of  the  methods  de- 
scribed. 

Step  6. — Attend  to  hemostasis.     Apply  dressings.     Immobilize. 

Riedl's  operation  is  only  suitable  in  cases  of  very  great  deformity  of  the 
first  metarsal  when  rectification  at  the  metatarso-phalangeal  articulation  would 
be  insufficient. 


Fig.   1 120. — {Weir.) 

Robert  F.  Weir's  Operation. — On  the  inner  side  of  the  foot  make  a  long- 
itudinal curved  incision  beginning  "in  front  at  the  hollow  of  the  phalanx 
(Fig.  1 1 20),  running  downwards  towards  the  sole,  and  encroaching  but  slightly 
on  it,  and  passing  backwards  and  upwards  to  the  middle  of  the  metatarsal  bone." 
Reflect  the  flap  thus  outlined.  With  a  chisel  or  bone  forceps  excise  such 
portions   of   bony   exostosis   as   prevent   reduction  of   the  deformity.     Freely 


BUNION. 


949 


divide  the  inner*  side  of  the  joint  capsule  (f.  e.,  the  side  next  to  the  second  toe). 
If  the  sesamoid  bones  are  dislocated  outwards,  remove  them.  Divide  the  dorsal 
tendon  near  its  insertion  and  suture  it  to  the  periosteum  at  the  outer*  side  of 
the  base  of  the  first  phalanx.  Close  the  wound.  For  two  or  three  weeks 
keep  a  pad  of  gauze  between  the  great  and  second  toes  to  help  hold  the  replaced 
toe  in  position.  In  the  hands  of  Weir  the  above  operation  has  given  excellent 
results.  Weir  remarks:  ''No  operation  for  the  hallux  valgus  is  well  done  that 
does  not,  before  suturing,  allow  the  toe  to  rest  easy  in  its  restored  position. 
If  any  tilting  then  exists,  its  cause  must  be  investigated  and  removed  or  an 
imperfect  result  will  ensue." 


Fig.  1 12 1. — {Mayo.) 


In  the  preceding  operations  any  inflamed  or  enlarged  bursa  existing  over 
the  osseous  deformity  must  be  excised. 

C.   H.  Mayo's   Operation. — This  operation  recognizes  that  excision  of 

the  head  of  the  metatarsus  is  calculated  to  leave  a  stiff  toe  and  seeks  to  avoid 

this  defect,     (i)  Reflect  a  flap  of  skin  (Fig.  1121)  downwards  on  the  inner  side 

of   the   metatarso-phalangeal    articulation.     Do   not   injure   the   bursa    (Fig. 

1 121).     (2)  Make  a  flap  of  the  subjacent  soft  parts  with  its  base  at  the  root  of 

the   great   toe.     Reflect   this  flap  and  with  it  the  bursa.     (3)  To  correct  the 

*  The  words  "outer"  and  "inner"  are  used  in  relation  to  the  middle  line  of  the  foot  and 
not  of  the  body. 


95° 


BUNION. 


C.  H.^\)o.y 


Fig.  II22. — {Mayo.) 


Fig.  1 1 23. — (Mayo.) 


BUNION.  951 

hallux  valgus  excise  the  head  of  the  metatarsus  and  shave  ofif  any  bony  ex- 
crescences. If  necessary,  excise  the  articular  surface  of  the  proximal  phalanx 
of  the  great  toe  (Fig.  1122).  (4)  Turn  the  flap  containing  the  bursa  into  the 
space  between  the  metatarsus  and  the  phalanx  and  fix  it  there  by  a  few  catgut 
sutures  (Fig.  11 23).  The  bursa  having  the  same  structure  as  a  joint  takes  the 
place  of  the  excised  joint.  (5)  Pvill  the  dorsal  flexor  tendon  of  the  great  toe 
inwards  so  as  to  lie  over  the  middle  of  the  new  joint  and  fix  its  sheath  in  this 
position  by  a  few  sutures.  (6)  Close  the  external  woimd.  Apply  alcohol 
dressings  to  the  wound  and  between  the  first  and  second  toes.  The  patient 
may  be  permitted  to  walk  in  a  few  days.  The  results  are  excellent.  This 
appeals  to  the  author  as  the  best  operation  for  bunion.  If,  when  the  patient 
is  first  seen,  the  bunion  is  inflamed,  it  must  be  treated  until  the  trouble  is 
quiescent  before  operation  is  attempted. 


CHAPTER  XCTI. 

OPERATIONS  ON  THE  SCAPULA  AND  CLAVICLE. 

Scapula  Alata.  Deformity  in  Serratus  Paralysis.^ — ^When  the  serratus 
magnus  and  the  trapezius  are  paralyzed  the  scapula  becomes  very  prominent 
and  abduction  of  the  arm  impossible. 

V.  Eiselsberg  united  the  two  scapulae  so  that  they  might  support  each  other 
and  thus  permit  abduction  of  the  arm.  When  he  succeeded  in  this  the  shoulders 
were  pulled  back  so  far  that  the  clavicles  compressed  the  vascular  and  nervous 
trunks  of  the  arm  against  the  first  rib,  and  to  overcome  this  it  was  necessary 
to  make  an  oblique  osteotomy  of  the  clavicle. 

Duval  gave  stability  to  the  scapula  by  uniting  it  to  the  sixth  and  seventh 
ribs  ("Revue  de  Chir.,"  1905,  No.  i). 

Duval's  Operation. — Step  i. — Make  an  incision  along  the  vertebral 
border  of  the  scapula  from  the  level  of  its  spine  down  to  its  angle.  Divide 
the  trapezius  and  rhomboideus  major  throughout  the  extent  of  the  wound. 
Retract  the  latissimus  dorsi  strongly  downwards  (Fig.  11 24). 

Step  2. — Incise  the  periosteum  along  the  exposed  border  of  the  scapula 
and  reflect  it,  along  with  the  infraspinatus,  from  the  bone  for  a  distance  of 
about  1/2  inch  (Fig.  11 24). 

In  the  same  manner  separate  the  periosteum,  along  with  the  serratus 
magnus,  from  the  deep  surface  of  the  scapula.  Excise  the  periosteum  and 
the  serratus  magnus  to  an  extent  sufficient  to  permit  the  denuded  under  surface 
of  the  scapula  to  lie  freely  in  contact  with  the  sixth  and  seventh  ribs. 

Step  3. — At  a  distance  of  2  3/4  inches  from  the  middle  line  denude  the 
sixth  and  seventh  ribs  of  their  periosteum.  To  give  the  scapula  proper  ob- 
liquity the  denudation  of  the  seventh  rib  should  be  about  1/2  inch  further 
out  than  that  of  the  sixth. 

Step  4. — Unite  the  scapula  to  the  ribs  by  two  wire  sutures  as  shown  in 
Figure  11 24. 

Step  5. — If  possible,  suture  the  periosteum  over  the  wires. 

Step  6. — Retract  the  inner  edge  of  the  wound  (skin,  trapezius,  rhomboid) 
and  expose  the  long  muscles  of  the  back  lying  on  the  posterior  surface  of  the 
transverse  processes  in  the  upper  angle  of  the  wound. 

Step  7. — From  the  long  muscles  of  the  back  make  a  long  and  thick  flap 
with  its  pedicle  below.  Suture  this  flap  at  the  superior  angle  of  the  scapula 
to  the  periosteum  and  the  supraspinatus. 

Step  8. — Close  the  wound  without  drainage.  Apply  dressings  and  a  plaster- 
of-Paris  corset  for  forty-eight  days. 

952 


SERRATUS   PARALYSIS. 


9S: 


Duval  has  operated  three  times.  His  first  patient  was  able  to  work  as  a 
waiter  without  trouble.  The  second  patient  was  improved.  The  third  was 
not  improved. 

Transplanatation  of  Muscle  in  Serratus  Paralysis.— Katzenstein 
("Berliner  klin.  Woch.,"  1908,  Dec.  28)  operated  in  two  stages  in  the  following 
manner: 

Stage  I. — Step  1. — Make  a  longitudinal  incision  near  the  middle  line  of  the 
back  from  the  third  to  the  tenth  dorsal  spines.  Expose  and  divide  the  portions 
of  the  trapezius  and  rhomboideus  major  arising  from  these  spines. 


Fig.  1 124. — -{Duval.) 


Step  2. — Reflect  the  divided  muscles  downwards  and  outwards  and  suture 
them  snugly  to  the  periosteum  of  the  seventh,  eighth,  and  ninth  ribs  and  to 
the  latissimus  dorsi. 

Stage  II. — Step  1. — Make  a  longitudinal  incision  along  the  inner  surface 
of  the  arm  from  its  middle  up,  through  the  axilla  to  end  on  the  thoracic  wall. 

Step  2. — Isolate  and  divide  the  humeral  insertion  of  the  pectoralis  major. 
Free  the  muscle  with  its  aponeurosis  and  suture  its  tendon  to  the  axillary 
border  and  to  the  anterior  scapular  muscles. 

The  result  was  excellent  both  as  regards  appearance  and  function. 

Muscle  Transplantation  in  Paralysis  of  the  Trapezius  and  Serratus 
Magnus. — In  a  case  of  complete  paralysis  of  the  trapezius  due  to  division  of 
its  nerve,  Katzenstein  ("Berliner  klin.  Wochsch.,"  xlvi  No.  49.)  operated  as 
follows: 


954 


OPERATIONS   ON   THE   SCAPULA  AND   CLAVICLE. 


First  Stage. — Through  a  suitable  incision  expose  the  upper  margin  of  the 
latissimus  dorsi  and  by  splitting  the  muscle,  isolate  a  suitable  bunch  of  its 
upper  fibres;  divide  this  isolated  segment  of  muscle  at  its  humeral  insertion 
thus  forming  a  flap  with  its  pedicle  posterior.  Suture 
the  free  end  of  the  flap  to  the  posterior  surface  of  the 
scapula  below  the  origin  of  the  triceps.  This  flap 
takes  the  place  of  the  lower  fibres  of  the  paralyzed 
trapezius  (Fig.  1125). 

Second  vS/a^g.— Through  a  suitable  incision  expose 
the  upper  part  of  the  healthy  (opposite)  trapezius. 
Divide  its  clavicular  insertion  and  carefully  preserving 
its  nerve  supply  form  a  muscular  flap  and  suture  it 
(Fig.  1 1 26)  to  the  spine  of  the  scapula. 

Third  Stage. — Form  a  flap  (Fig.  11 27)  from  the 
middle  of  the  healthy  trapezius  and  suture  its  free 
extremity  alongside  of  the  flap  formed  in  the  second 
stage  of  the  operation. 

The  result  of  Katzenstein's  operation  was  function- 
ally  good.      In    complete    paralysis   of   the   serratus 
magnus  and  partial  paralyses  of  the  inferior  fibres  of 
the  trapezius  Katzenstein  devised  and  carried  out  the 
following  procedure: 

I.  Division  of  the  spinal  origin  of  the  rhomboid  muscles  and  transplanta- 
tion of  their  origin  to  lower  vertebrae  thus  reversing  the  action  of  the  muscles 


Fig.  1 1 25. — {Katzenstein.) 
I,  2,  3.  Sup.  Mid.  and 
Inf.  Segments  of  trape- 
zius. 4.  Latissimus 
Dorsi.  5.  Flap  from  Lat. 
Dorsi  to  trapezius. 


Fig.  1126. — {Katzenstein.) 

I.  Sup.  fibres  of  paralysed  trapezius. 

Flap  from  healthy  trapezius. 


Fig.  1127. — {Katzenstein.) 
I,  2,  4.  Sup.  Med.  and  inferior  segments 
of  trapezius.     3.  Flap  transplanted  from  left 
to  reinforce  right  trapezius. 


and  making  them  assistants  to  instead  of  antagonists  of  the  serratus  magnus. 
2.  Division  of  the  tendon  of  the  pectoralis  major  at  the  level  of  the  humerus  and 
suture  of  it  to  the  axillary  border  of  the  scapula  so  as  to  correct  the  scapula 
alatum  which  was  present.     The  result  was  excellent. 


DELTOID    PARALYSIS.  955 

Paralysis  of  Trapezius  Muscle. — Treatment  by  "free"  transplantation  of 
fascia.  Rothschild's  operation  when  the  upper  arm  is  raised  above  the  horizontal 
this  motion  is  due  to  the  serratus  magnus  while  the  trapezius  keeps  the  scapula 
sufficiently  fixed  so  that  the  serratus  is  able  to  act  with  power.  If  the  trapezius 
is  paralyzed  it  becomes  impossible  to  raise  the  arm  unless  the  scapula  is  held 
in  place  by  some  artificial  means.  Rothschild  accomplishes  the  fixation  of  the 
scapula  in  the  following  manner.     ("Zeit.  fiir  Chir.,"  Nov.  5,  1910.) 

Step  I. — Make  an  oblique  incision  from  the  upper  and  inner  angle  of  the 
scapula,  downwards  to  the  first  lumbar  vertebra.  Expose  the  vertebral 
border  of  the  scapula,  part  of  the  paralyzed  trapezius,  part  of  the  latissimus 
dorsi. 

Step  2. — From  the  thigh  excise  a  strip  of  fascia  lata  about  8  inches  long  and 
13/4  inches  wide. 

Step  3. — Suture  one  end  of  the  strip  of  fascia  securely  to  the  supraspinatus 
and  its  fascia.  Suture  the  other  end  of  the  strip  to  the  latissimus  dorsi  and  deep 
muscles  near  the  spine.  Before  suturing  the  vertebral  end  of  the  strip  of  fascia 
put  so  much  tension  on  it  that  the  scapula  is  pulled  up  to  the  level  of  its  fellow 
on  the  opposite  side  and  its  vertebral  border  is  parallel  to  the  spine.  In  order 
to  prevent  adhesion  between  the  fascial  implant  and  the  skin,  Rothschild 
recommends  that  a  small  opening  be  made  through  the  paralyzed  trapezius 
near  the  scapula  and  that  the  flap  be  passed  through  this  opening  and  conducted 
under  the  trapezius  to  the  site  of  its  suture  to  the  trapezius.  Rothschild  has 
found  this  operation  completely  satisfactory. 

Deltoid  Paralysis. — -Transplantation  of  Trapezius. — Dean  Lewis' 
operation.     ("Journ.  A.  M.  A.,"  Dec.  24,  1910. 

Step  I. — Make  a  longitudinal  incision  from  the  middle  of  the  outer  border  of 
the  trapezius  to  the  junction  of  the  middle  and  lower  thirds  of  the  deltoid. 

Step  2. — Divide  the  clavicular,  acromial  and  part  of  the  spinous  attachments 
of  the  trapezius. 

Step  3. — Separate  the  artophied  deltoid  from  the  clavicle  and  spine  of  the 
scapula  and  turn  it  down. 

Step  4. — Open  the  sheath  of  the  long  head  of  the  biceps,  lift  up  the  tendon 
and  plicate  it  (Kiliani)  so  as  to  correct  the  subluxation. 

Step  5. — Suture  the  trapezius  to  the  articular  capsule  where  it  is  attached 
to  the  humerus. 

Step  6. — Turn  the  flap  of  deltoid  upwards  over  the  trapezius  and  suture 
it  high  up  while  the  arm  is  abducted. 

Step  7. — Suture  the  upper  part  of  the  skin  wound  in  such  a  manner  as  to 
make  the  cicatrix  at  right  angles  to  the  original  direction  of  the  wound.  This 
helps  to  overcome  the  subluxation.  Close  the  rest  of  the  wound.  The  re- 
sulting scar  is  T-shaped  the  horizontal  arm  of  the  T  extending  across  the  sum- 
mit of  the  shoulders. 

Step  8. — Apply  dressings.  Immobilize  at  an  angle  of  about  100°.  After 
about  four  or  five  weeks  gradually  lower  the  arm. 


956  OPERATIONS    ON    THE    SCAPULA   AND    CLAVICLE. 

Excision  of  the  Scapula. — Indication. — ^Malignant  neoplasms  of  the 
scapula  constitute  the  indication  for  its  complete  removal.  As  a  rule,  as 
much  as  possible  of  the  muscles  attached  to  the  bone  should  be  removed  along 
with  it,  since  sarcoma  is  liable  to  spread  from  the  bone  along  the  muscles  (see 
remarks  on  tumors  of  bone).  If  skin  is  involved,  the  incisions  must  be  so 
planned  as  to  surround  the  affected  areas. 

If  the  humerus  or  axilla  are  involved,  the  question  of  inter-scapulo-thoracic 
amputation  at  once  arises.  If  the  scapula  is  fixed  to  the  chest  wall,  operation 
is  usually  contraindicated  as  the  thorax  is  invaded. 

Step  I. — Place  the  patient  on  his  back.  Abduct  the  arm.  From  the  apex 
of  the  axilla  make  a  3-inch  incision  down  the  arm,  immediately  behind  the  an- 
terior wall  of  the  axilla,  along  the  inner  and  posterior  border  of  the  coraco- 
brachialis.  Raise  the  anterior  fold  of  the  axilla  and  expose  the  coracoid  process. 
With  blunt-pointed  scissors  cut  the  three  muscles  attached  to  the  coracoid  close 
to  the  bone.  This  fully  exposes  the  axUlary  artery.  The  subscapular  artery 
"arises  opposite  the  lower  border  of  the  subscapularis  and  runs  downwards 
and  inwards  along  the  anterior  border  of  that  muscle  under  cover  of  the  latissi- 
mus  dorsi.  *  *  *  It  is  accompanied  by  two  veins.  *  *  *  About  2.5 
or  3.7  cm.  (i  or  i  1/2  inches)  from  its  origin,  the  subscapular  artery  divides 
into  two  end  branches:  (i)  the  circumflex  (dorsal)  scapular,  and  (2)  the  dorsal 
thoracic"  (Morris)  (Fig.  11 28).  Recognize  and  ligate  the  subscapular  artery. 
This  step  (Cheyne,  Jacobson)  saves  much  trouble  from  bleeding  and  the  sepa- 
ration of  the  muscles  attached  to  the  coracoid  greatly  simplifies  the  later  stages 
of  the  operation.  The  truth  of  these  observations  was  agreeably  impressed  on 
the  author  in  a  case  of  gigantic  enchondroma  in  which  he  was  associated  with 
Dr.  Sudler. 

Step  2. — Pack  the  axillay  wound.  Turn  the  patient  on  to  his  sound  side 
and  bring  his  back  close  to  the  edge  of  the  table. 

Incision  A. — Make  "a  T-shaped  incision,  one  limb  running  from  the 
acromio-clavicular  joint  inwards  to  the  superior  angle  of  the  scapula,  while  the 
other  and  longer  is  made  at  right  angles  to  the  first  down  to  the  angle  of  the 
scapula." 

Incision  B. — Make  a  H  -shaped  incision,  one  cut  running  a  long  the  verte- 
bral border  of  the  scapula,  the  other  at  right  angles  to  it  across  the  centre  of  the 
growth. 

Incision  C. — Same  as  B  except  that  the  horizontal  cut  runs  on  the  spine  of 
the  scapula  and  reaches  to  the  acromio-clavicular  joint  or  if  a  portion  of  the 
acromion  is  to  be  preserved,  to  the  top  of  the  acromion. 

Step.  3. — Incision  C  has  been  adopted.  Reflect  the  two  skin  flaps  formed 
by  the  H  -shaped  cut.  Examine  the  deltoid  and  trapezius  muscles.  If  their 
condition  is  above  suspicion,  preserve  them;  if  not,  those  portions  which  are 
attached  to  the  scapula  must  be  excised.  Pass  the  finger  under  the  deltoid 
and  hook  up  the  muscle.  If  the  muscle  is  to  be  preserved  divide  its  origin  at  the 
spine  of  the  scapula  and  reflect  the  muscle  outwards;  if  it  is  to  be  removed 


EXCISION   SCAPULA. 


957 


split  the  muscle  along  the  junction  of  its  scapular  and  clavicular  portions. 
Follow  the  scapular  portion  down  to  its  insertion  in  the  humerus  and  there 
divide  it,  leaving  the  muscle  hanging  attached  to  the  scapula.  The  clavicular 
portion  of  the  deltoid  is  left  intact. 


OELTOID  PECTOKAL 
TR/ANGIE 

THUKACO-\  BRANCH. 
acromial]  0ELTO16. 
ARTERVy      BRANCH 


PECTORAL/fi 
MAfJOR  MUSCLE' 


CORA  CO  -BRA  CH/AL  IS 
MUSCLE 

BRA  CH/AL  ARTERY- 


SELTOID  MUSCLE 


RJCEfS  MUSCLE 


SC/BSCAPULAR  ARTERY 

AVXlLLAJtyurMPH-NODES 

DORSAL  THORACIC 
,         ARTERY" 


CIRCUMFLEX 
,   SCAPVLAS 
--"'        ARTERY 


/,  IT/SSIMUS 
DORSI  MUSCLE 
_  TRrCEPS  MUSCLE 
(LONGHBAD) 

TENDINOUS  CONNECT/ON  or 
-—    THE  TRICEPS  WITH  THB 
LATISSfMUS  DURSr 

PROFUNDA  ARTERY 


TRICEPS  MUSCLE 
'  r MIDDLE  HEAD) 

SUPERIOR  ULNAR 
COLLATERAL  ARTERY 


CUTANEOUS 
BRANCHES 


BRACfHAL  ARTERY  - 
LACERTUS   E/BROSUS 


BRACHIAL  MUSCLE 


.IJVEBRIOR  ULNAR 
COLLATERAL  ARTERY 


-CUTANEOUS  BRANCH 


ANTIBRACHfAL 
FASCIA 


Fig.   1 128. — {^Morris.) 


Step  4. — E.xpose  and  divide  the  following  tendons  which  are  inserted  into 
or  near  the  upper  end  of  the  humerus — subscapularis,  the  long  head  of  the  biceps, 
supra-spinatus,  infra-spinatus,  teres  minor  and  major.  The  capsule  of  the 
shoulder-joint  is  of  course  opened.  In  the  upper  and  outer  part  of  the  wound 
under  the  head  of  the  humerus,  lies  the  long  head  of  the  triceps;  isolate  and 
divide  this  carefully,  avoiding  injury  to  the  circumflex  nerve  going  to  the  deltoid. 


958 


OPERATIONS    ON    THE    SCAPULA  AND    CLAVICLE. 


If  part  of  the  acromion  process  is  to  be  preserved,  divide  it  at  the  desired  spot; 
if  not,  separate  the  soft  structures  from  it  and  freely  open  the  acromio-clavicular 
articulation. 

Step  5. — Pass  the  linger  under  the  trapezius  muscle  and  treat  it  exactly  as 
the  deltoid  was  treated,  i.  e.,  either  divide  it  at  its  insertion  along  the  upper  edge 
of  the  spine  of  the  scapula  and  reflect  it  upwards,  or  separate  (by  splitting)  its 
clavicular  from  its  scapular  portions  and,  separating  the  latter  from  the  chest- 
wall,  divide  it  as  near  its  origin  as  possible,  leaving  the  muscle  to  be  removed 
attached  to  the  scapula. 

Subscapular  branch  of  transverse  scapular  artery 
Supraspinous  branch  0/  transverse  scapular  artery 


Descending  branch 
of  transverse  cer- 
vical artery 


Supraspinous  branch 
Subscapular  branch 


Branch  of  intercostal    ^\  (  '4m. 


artery 


Branch  of  intercostal     V— 'l\  \    -v'^ 

artery  ~^\\  <:' 


Continuation  of  de- 
scending branch 
of  transverse  cer- 
vical artery 


Transverse  scapular  artery 


'/ 


Acromial  branch  of 
th  oraco-aciomial 
Acromial  rete 


Subscapular  branch  of 

transverse  scapular 

artery 
Ivfraspinous  branch  of 

transverse  scapular 

artery 
Stibscapular  branch  of 

axillary  artery 


Circumflex  scapular  branch        • 
of  subscapular  artery  ■ 


Branch  oj  eircnmflez 
scapular  artery 


Dorsal  thoracic  branch  of 
subscapular  artery 


i 


Fig.   1 129. — The  anastomoses  about  the  scapula. — (Morris.) 


Step  6.- — At  the  upper  border  of  the  neck  of  the  bone  detach  the  omo-hyoid. 
Ligat  and  divide  the  surpa-scapular  (transverse  scap.)  artery  (Fig.  1129). 
Divide  the  levator  anguli  scapulae  at  the  upper  angle  of  the  bone  and  ligate  and 
divide  the  posterior  scapular  (descending  branch  transverse  cervical)  artery. 
Divide  the  rhomboids  and  the  serratus  magnus. 

Step  7. — Complete  the  division  of  the  capsule  of  the  shoulder-joint.  The 
first  step  in  the  operation  has  attended  to  the  freeing  of  the  coracoid  process  and 
ligation  of  the  subscapular  artery.     Remove  the  scapula. 


EXCISION   SCAPULA.  959 

Step  8. — Attend  to  hemostasis.  Quenu  unites  the  antero-inferior  part  of 
the  capsule  to  the  soft  parts  under  the  clavicle.  With  a  wire  suture  he  unites 
the  upper  part  of  the  capsule  to  the  scapula  through  which  a  hole  is  bored  to  re- 
ceive the  wire.  The  long  head  of  the  biceps  is  sutured  in  the  same  fashion  to 
the  clavicle.  (If  the  scapular  portion  of  the  deltoid  has  been  preserved,  suture 
its  lower  part,  if  possible,  to  the  rhomboid;  its  upper  part  to  the  trapezius.) 
Close  the  wonnd  providing  freely  for  drainage. 

"The  results  are  excellent;  the  patient  retains  all  movements  of  the  limb, 
with  the  exception  that  he  is  unable  to  abduct  the  arm  above  a  right  angle  from 
the  trunk"  (Burghard). 

Subperiosteal  Excision  Scapula  (Oilier). — Indication  for  operation  is 
usually  osteomyelitis  with  its  complications  and  sequelae. 

Step  I. — Make  an  incision  down  to  the  bone  along  the  spine  of  the  scapula 
from  the  acromion  to  the  vertebral  border.  With  knife  and  elevator  separate 
the  trapezius  from  the  scapular  spine. 

Step  2. — Make  an  incision  along  and  expose  the  whole  vertebral  border  of 
the  scapula.  Through  this,  subperiosteally,  separate  the  soft  parts  from  the 
bone  both  above  and  below  the  scapular  spine. 

Step  3. — Pull  the  vertebral  edge  of  the  scapula  away  from  the  chest  and 
subperiosteally  separate  the  subscapularis  and  all  other  soft  structures  from 
the  anterior  surface  of  the  scapula — until  the  axillary  border  and  the  neck  of 
the  bone  are  reached. 

Step  4. — Divide  the  acromio-clavicular  joint  from  below  upwards.  Divide 
the  articular  capsule  and  the  tendinous  insertions  on  the  upper  end  of  the  humer- 
us. Divide  the  base  of  the  coracoid  process.  Unless  it  is  absolutely  necessary 
to  remove  the  head  of  the  scapula  it  is  better  to  divide  the  neck  of  the  bone 
and  leave  the  articulating  surface  intact. 

Subperiosteal  resection  when  indicated  is  a  much  easier  operation  than  the 
same  procedure  carried  out  on  the  normal  cadaver  because  disease  thickens  the 
periosteum  and  loosens  it  from  the  bone.  After  subperiosteal  excision  the  bone 
is  often  almost  completely  regenerated. 

Partial  Excision  of  the  Scapula. — Almost  any  portion  of  the  scapula  may 
be  excised  through  suitable  incisions,  and  such  operations  require  no  special 
description. 

Excision  of  the  Clavicle.— Subperiosteal  resection  of  the  clavicle  may  be 
demanded  in  the  treatment  of  necrosis. 

Step  I. — Make  a  cut  along  the  clavicle  from  the  acromion  process  to  the 
sternum.     Divide  the  periosteum. 

Step  2. — With  an  elevator  separate  the  periosteum  from  the  front  surface  of 
the  bone.  With  a  curved  elevator  (many  elevators  are  provided  with  a  point 
which  while  blunted  is  still  sharp  enough  to  do  damage  if  a  slip  occurs,  the  end 
of  the  best  elevator  is  more  or  less  square  with  rounded  angles)  hugging  the  bone 
separate  the  periosteum  from  the  posterior  surface  of  the  bone  near  its  middle. 

Step  3. — (a)  With  Gigli's  saw  or  bone  forceps  divide  the  bone  near  its  middle. 


960 


OPERATIONS    ON    THE    SCAPULA   AND    CLAVICLE. 


Grasp  the  end  of  the  inner  fragment  with  strong  forceps  and  pull  it  forwards. 
It  is  now  easy  to  separate  the  fragment  from  the  surrounding  soft  parts  by 
blunt  dissection  aided  by  an  occasional  snip  of  the  scissors  (the  scissors  must  be 
made  to  cut  against  the  bone)  and  so  to  remove  the  whole  inner  end  of  the  bone. 
It  is  always  best  if  possible  to  divide  the  bone  near  its  sternal  articulation  and 
to  leave  the  articular  end  of  the  bone  in  situ.  Do  the  same  to  the  outer  end  of  he 
bone.  The  insertion  of  the  subclavius  at  the  junction  of  the  outer  and  middle 
thirds  of  the  bone  requires  sharp  division  (always  cutting  on  the  bone).  The 
coraco-and  acromio-clavicular  ligaments  require  division  with  knife  or  scissors, 


Trapezoid 
ligament 


Tendon  of  sub- 
scapularis  muscle 


Cansule  of  the 
acromio-clavicular 
joint. 
Coraco-acromial 

ligament 

Coraco-humeral 

ligament 


Transverse 
humeral-liganient 


Tendon  of  biceps 


Fig. 


1 130. 


-Outer  view  of  the  shoulder-joint,  showing  the  coraco-humeral  and  transverse 
humeral  ligaments.— (Morrw.) 


if  the  outer  extremity  of  the  bone  is  to  be  sacriticed,  but  it  is  always  best  to  save 
the  acromio-clavicular  joint  if  possible. 

(b)  Intsead  of  dividing  the  clavicle  at  its  middle,  divide  it  near  its  outer 
end  or  open  the  acromio-clavicular  joint.  Seize  the  outer  mobilized  end  of  the 
bone  and  pull  it  forwards.  Separate  the  bone  from  the  soft  parts  subperiosteally 
and  remove  it  entire  or  in  part. 

Step  4 — Cleanse  and  close  the  wound,  providing  for  very  free  drainage 
which  is  necessary  because  the  operation  is  generally  performed  for  necrosis. 
Treat  as  a  fractured  clavicle. 

Excision  of  Clavicle  for  Sarcoma. — Step  i. — Make  an  incision  through 
the  skin  alone  along  the  whole  length  of  the  bone.     Supplement  this  cut  by 


DISLOCATION   CLAVICLE.  961 

vertical  ones,  if  required  for  the  reflection  of  the  skin  from  over  the  whole  of 
the  tissues  to  be  removed. 

Step  2. — Expose  the  outer  edge  of  the  clavicular  insertion  of  the  sterno- 
mastoid.  Pass  a  finger  or  director  (the  author  for  such  purposes  used  a  closed 
blunt-pointed  scissors  curved  on  the  flat)  behind  the  clavicular  portion  of  the 
muscle  and  divide  it  at  a  safe  distance  from  the  disease.  Expose  the  inner 
edge  of  the  clavicular  insertion  of  the  trapezius  and  divide  it  in  the  same  manner. 
In  the  same  fashion  divide  such  portions  of  the  pectoralis  major  and  the  deltoid 
as  are  attached  to  the  cla\ncle. 

Step  3. — Mobilize  the  acromial  end  of  the  bone  by  dividing  the  acromio-and 
coraco-clavicular  ligaments.  This  is  a  difficult  step  (Fig.  1 130) .  Pull  the  outer 
end  of  the  clavicle  forwards.  Remember  the  subclavian  vein  which  is  separated 
from  the  bone  by  the  subclavius  muscle.  Separate  the  bone  and  tumor  up  to 
the  claviculo-sternal  articulation.     Disarticulate. 

Step  4. — Attend  to  hemostasis.  Close  the  wound.  Dress.  Treat  like  a 
fracture  of  clavicle. 

The  results  as  regards  use  of  the  arm,  strange  to  say,  are  reported  to  be  most 
excellent. 

Presternal  Dislocation  of  the  Clavicle. — Grunert  ("Med.  Klinik."  May 
29,  1910)  recommends,  in  presternal  dislocation  of  the  clavicle,  that  the  meniscus 
of  the  sterno-clavicular  joint  be  excised  and  the  bones  united  by  three  sutures. 


61 


CHAPTER  XCIII. 
SHOULDER. 

EXCISION  OF  THE  SHOULDER-JOINT. 

OlUer's  Operation  or  Subperiosteal  Resection. — Step  i. — Abduct  the 
arm  moderately  and  have  an  assistant  hold  it  steadily.  From  a  point  1/2  inch 
below  the  clavicle  and  beside  the  coracoid  process  make  an  incision  4  1/2  to 
5  inches  in  length,  which  is  directed  downwards  and  outwards  towards  the  inser- 
tion of  the  deltoid  (Fig.  1131).  The  incision  divides  the  skin  and  subcutaneous 
tissues.  Distinguish  the  anterior  or  internal  (pectoro-deltoid  groove)  border 
of  the  deltoid.  Incise  the  deltoid  a  little  to  the  outside  of,  and  parallel  to  its 
internal  margin,  thus  avoiding  injury  to  the  cephalic  vein  and  a  large  branch 

of  the  acromio-thoracic  artery.  Retract  the 
outer  side  of  the  wound  (skin  and  deltoid), 
thus  exposing  the  head  of  the  humerus. 

Step  2. — Rotate  the  arm  so  as  to  make  out 
the  bicipital  groove.  Incise  the  joint  capsule 
throughout  its  whole  extent  parallel  and  ex- 
ternal to  the  tendon  of  the  biceps.  Do  not 
injure  the  acromio-coracoid  ligament.  Pro- 
long the  capsular  incision  downwards  on  the 
humerus,  dividing  the  periosteum,  to  the  point 
where  it  is  desired  to  sever  the  bone  (Fig. 
1 13 2).  Introduce  a  sharp  but  not  pointed 
periosteal  elevator  and  separate  the  periosteum 
and  tendinous  insertions,  on  the  outer  side  of 
the  wound,  from  the  external  or  greater  tuber- 
osity. As  the  separation  progresses  the  assistant 
rotates  the  humerus  inwards.  In  using  the 
sharp  elevator  keep  the  edge  of  the  instrument  firmly  pressed  against  the  bone, 
and  when  there  is  danger  of  tearing  the  periosteum  endeavor  to  sacrifice  bone 
rather  than  impair  the  integrity  of  its  fibrous  covering.  If  these  rules  are  ob- 
served, the  tendinous  insertions  and  periosteum  will  be  raised  from  the  bone 
together  and  remain  attached  to  the  fibrous  capsule  of  the  joint.  One  is  rarely 
completely  successful  in  this,  but  even  partial  success  is  beneficial.  The  ex- 
ternal tuberosity  having  been  denuded,  open  the  sheath  of  the  biceps  tendon, 
lift  the  tendon  from  its  groove  and  retract  it  inwards.  Separate  the  periosteum 
and  tendinous  insertions  from  the  internal  or  lesser  tuberosity  in  the  manner 
already  described,  while  doing  so  have  the  assistant  rotate  the  arm  outwards. 

962 


Fig. 


1131. 


EXCISION   SHOULDER. 


963 


Make  the  head  of  the  humerus  protrude  into  the  wound  by  carrying  the  elbow 
backwards  and  upwards.  Separate  the  posterior  and  lateral  fibrous  attach- 
ments from  the  bone  by  the  method  already  desciibed  (Fig.  1133). 

Step  3. — Examine  the  head  of  the  bone  and  make  it  protrude  out  of  the 
wound  (Fig.  1 134) .  Saw  off  as  much  of  the  upper  end  of  the  humerus  as  is  ren- 
dered necessary  by  the  presence  of  disease. 


Fig.   ii^: 


-{Schifartz.) 


Step  4. — Examine  the  glenoid  cavity  and  if  disease  is  present  remove  it  with 
a  sharp  spoon,  chisel,  or  ronguer  forteps. 

Step  5. — With  forceps  and  scissors  dissect  away  all  diseased  synovialis. 
The  walls  of  all  sinuses  must  be  removed  by  dissection  or  by  curettement. 

Step  6. — Provide  for  posterior  tubular  drainage  by  an  incision  in  an  appro- 
priate position  behind.  Rub  the  wound  with  iodoform.  Provide  for  drainage 
of  anterior  wound  and  partially  close  it  with  sutures.     Apply  dressings.     A 


Fig.   1133.- — -{Schwartz.) 


large  pad  must  be  placed  in  the  axilla  to  keep  the  upper  end  of  the  humerus 
from  falling  inwards  and  the  elbow  and  forearm  bandaged  to  the  chest.  As 
soon  as  the  wound  has  healed,  the  tone  of  the  shoulder  muscles  may  be  kept  up 
by  applications  of  electricity.  No  passive  movements  or  massage  must  be 
attempted  before  the  lapse  of  about  eight  weeks  and  the  movements  of  ab- 
duction must  be  the  last  to  be  used.     The  reason  for  delaying  movement 


964  SHOULDER. 

is  that  one  must  wait  until  the  upper  end  of  the  humerus  has  become  to  some 
extent  fixed  in  its  new  position  and  thus  avoid  an  undesirable  "flail-joint." 

In  some  cases  where  the  tissues  have  not  been  softened  by  inflammation 
it  is  very  difficult  to  detach  the  periosteum  and  tendinous  insertions  from  the 
major  and  minor  tuberosities  of  the  humerus.  After  this  feat  has  been  attempted 
the  detached  periosteum  is  usually  a  thing  of  "shreds  and  patches."  In  the 
case  of  the  hip-and  ankle-joints  Konig  has  overcome  this  difficulty  by  chiseling 
off  from  the  main  bone  a  shell  of  bone  and  retracting  it  along  with  its  periosteal 
and  tendinous  attachments.  The  method  has  so  many  good  features  in  addition 
to  its  simplicity  that  the  author  suggests  its  application  to  the  shoulder-joint. 

Expose  the  shoulder  through  the  Oilier  incision.  Divide  the  periosteum 
of  the  humerus  along  the  outer  edge  of  the  bicipital  groove.     Place  a  chisel 


Fig.   1 134. — {Schwartz.) 


in  position  with  its  edge  against  the  outer  margin  of  the  bicipital  groove  and  cut 
through  the  great  tuberosity  (Fig.  1 135).  Reflect  the  detached  shell  of  bone  with 
all  its  connections  outwards.  Lift  the  long  tendon  of  the  biceps  outwards. 
With  the  chisel  cut  the  lesser  tuberosity  free  from  the  shaft  of  the  humerus. 
Reflect  inwards  the  shell  of  bone,  with  its  periosteal  connections  and  with  the 
long  head  of  the  biceps.  Dislocate  the  head  of  the  humerus  into  the  wound, 
at  the  same  time  severing  its  posterior  attachments  with  periosteal  elevator  or 
scissors  as  already  described. 

After  the  active  operation  is  completed,  examine  the  shells  of  bone  which 
remain  attached  to  the  periosteum.  If  they  show  evidences  of  disease,  remove 
them;  if  not,  replace  them.  When  the  shells  of  bone  are  replaced,  arrange  them 
in  such  a  manner  that  the  long  tendon  of  the  biceps  will  remain  superficial  to 
them. 

Atypical  Resection  of  the  Shoulder. — In  children  it  is  especially  desirable 
to  avoid  typical  resection  of  the  upper  end  of  the  humerus,  because  injury  to, 
or  destruction  of  the  epiphyseal  cartilage  leads  to  non-development  of  the  upper 
arm.  In  suitable  cases  one  can  expose  the  joint  by  the  Oilier  method,  examine 
the  head  of  the  humerus  and  the  glenoid  cavity  and  with  chisel  and  sharp  spoon 
remove  any  osteal  foci  of  disease  which  may  be  found.  The  principles  of  treat- 
ment are  the  same  as  in  the  case  of  the  knee-joint. 

Resection  of  the  Shoulder  from  Behind     (Kocher). —  When  the  glenoid 


EXCISION    SHOULDER. 


965 


cavity  is  much  diseased  or  the  arthritis  is  very  diffuse,  the  usual  anterior  routes 
do  not  give  sufficiently  free  access  to  the  joint.  For  these  cases  Kocher  has 
devised  the  following  operation: 

Step  I. — Beginning  at  the  acromio-clavicular  joint,  make  an  incision  along 
the  upper  margin  of  the  spine  of  the  scapula  to  about  the  middle  of  that  bone; 


Fig.  I 135. 

A.  External  shell  of  bone  (major  tuberosity  held  outwards  by  chisel);  B.  Internal  shell  of 

bone  retracted  inwards;  C.  Bicipital  groove. 


from  this  point  continue  the  incision  in  a  curve  downwards  and  outwards  to 
about  two  fingers'  breadth  from  the  posterior  axillary  fold  (Fig.  1136). 

Step  2. — Open  the  acromio-clavicular  joint.  Divide  the  insertion  of  the 
trapezius  into  the  spine  of  the  scapula  throughout  the  length  of  the  wound. 
Expose  the  posterior  margin  of  the  deltoid,  push  the  finger  under  the  deltoid 
and  separate  it  from  the  underlying  infraspinatus.     Divide  a  portion  of  the 


966 


SHOULDER. 


Trapezius 
Deltoid 

Infraspinatus] 

Teres  major] 


Fig.   1 136. — [Kucher.) 


Acromion 


Acromioclavic- 
ular joint 


: Trapezius 

-  Crest  ot  scapula 

-Deltoid 


tlG.   1 137. — [Kocher) 


EXCISION   SHOULDER. 


967 


origin  of  the  deltoid  posteriorly  (Fig.  113 7).  Push  the  finger  along  the  lower 
surface  of  the  spine  of  the  scapula,  between  the  deltoid  and  the  infraspinatus 
to  the  place  where  the  infraspinatus  loses  touch  with  the  spine.  Bluntly  push 
the  supraspinatus  away  from  the  upper  surface  of  the  spine  until  the  finger  can 
be  hooked  round  the  outer  end  of  the  spine. 

Step  3. — Method  A. — With  a  chisel  make  an  oblique  section  of  the  spine  of 
the  scapula,  so  that  the  acromion  process  and  the  whole  crest  of  the  scapular 
spine  from  which  the  deltoid  arises  are  separated  from  the  body  of  the  bone. 
Before  dividing  the  bone  it  may  be  well  to  drill  holes  in  the  bone  on  each  side  of 
the  line  of  section  so  as  to  be  able  conveniently  to  wire  the  fragments  on  com- 
pletion of  the  operation.  Instead  of  boring  holes,  one  may  subperiosteally 
resect  a  small  fragment  of  bone  on  each  side  of  the  line  of  section,  thus  leaving 


Clavicular  joint 

Acromial  joint 

Tendon  biceps  • 

Fragment  scapula 

Deltoid 

Joint  capsule 
incised 


Supraspinatus 

Cut  surface  crest  of 
scapula 

'    Infraspinatus 


Fig.   1138. — (Kocher) 

small  flaps  or  tags  of  periosteum  which  may  be  sutured  together.  In  dividing 
the  bone  be  careful  not  to  injure  the  supra-scapular  nerve  as  it  goes  through  the 
great  scapular  notch. 

Method  B. — -Instead  of  cutting  off  the  mass  of  the  spine  of  the  scapula, 
merely  cut  oft",  subcortically,  that  portion  from  which  the  deltoid  arises. 

Step  4. — Turn  downwards  the  flap  of  deltoid  muscle  with  its  bony  attachments 
(Fig.  1 138).  This  exposes  very  freely  the  outer  and  posterior  surfaces  of  the 
head  of  the  humerus  with  the  attachments.  Rotate  the  arm  outwards.  Make 
a  longitudinal  incision  down  to  the  bone  along  the  posterior  margin  of  the  bi- 
cipital groove  and  expose  the  biceps  tendon  up  to  its  origin  above  the  glenoid 
cavity. 

Step  5. — Beginning  at  the  posterior  margin  of  the  bicipital  groove,  separate 
the  periosteum,  and  with  it  the  external  rotators  of  the  humerus,  from  the  greater 
tuberosity,  and  retract  these  structures  backwards.  Inspect  the  biceps  tendon 
and  its  sheath.    Retract  the  tendon  forwards.    By  flexing  the  elbow,  rotating  the 


968  SHOULDER. 

shoulder,  pushing  the  head  through  the  wound,  etc.,  etc.,  it  is  now  possible  to 
inspect  the  whole  joint  and  judge  if  it  is  necessary  to  resect  the  joint  or  if  a  mere 
arthrotomy  will  suffice. 

If  arthrectomy  is  necessary  proceed  to 

Step  6. — Subperiosteally  separate  the  insertions  of  the  muscles  from  the  lesser 
tuberosity  forwards  and  inwards.  Complete  the  resection,  removing  all  diseased 
tissue. 

Step  7. — Replace  the  deltoid  flap  and  fix  it  in  position  by  sutures.  Provide 
drainage.     Dress. 

Kocher's  operation  sounds  formidable,  but  innervation  is  well  preserved  and 
the  after-results  are  remarkably  good.  If  partial  resection  is  sufficient  Kocher's 
method  permits  the  anterior  part  of  the  capsule,  the  subscapular  muscle  and  the 
coraco-humeral  ligament  to  remain  uninjured,  thus  avoiding  subsequent  dis- 
location. 

Excision  Shoulder. — A  rational  method  of  resection  must  comply  with  the 
following  conditions:     Catterina  ("  Zentralblatt  fiir  Chir,"  1906,  No.  2). 

1.  It  must  be  safe  and  must  hazard  no  important  structures. 

2.  It  must  be  easy. 

3.  It  must  afford  a  good  view  of  all  parts  of  the  joint  cavity. 

4.  It  must  be  suitable  to  all  cases  requiring  resection. 

Catterina  endeavors  to  fulfil  these  requirements  by  temporary  resection  of 
the  outer  third  of  the  clavicle,  thus  obtaining  free  exposure  of  the  joint  and 
avoiding  injury  to  the  deltoid  and  to  the  circumflex  nerve.  The  method  is 
suitable  to  all  cases,  especially  to  those  of  old  anterior  dislocations  requiring 
reduction  or  excision. 

Step  I. — From  a  point  about  2  inches  above  the  junction  of  the  middle  and 
outer  thirds  of  the  clavicle  make  an  incision  downwards  and  outwards  through 
the  skin  and  fascia  for  about  6  inches  along  the  groove  between  the  pectoralis 
major  and  the  deltoid.     Retract,  or  doubly  ligate  and  divide,  the  cephalic  vein. 

Step  2. — At  the  junction  of  its  middle  and  outer  thirds  separate  the  soft 
parts  from  the  clavicle  sufficiently  to  bore  two  holes  through  the  bone  about 
3/4  inch  apart.  Midway  between  these  two  holes  (which  will  serve  for  future 
wiring)  divide  the  bone  with  a  Gigli  wire  saw. 

Step  3. — Rotate  the  external  portion  of  the  clavicle  outwards  and  divide  its 
connections  with  the  trapezius,  the  subclavius,  and  the  coraco-clavicular  liga- 
ment.    Leave  the  clavicular  origin  of  the  deltoid  intact  (Fig.  1139). 

Step  4. — Reflect  the  flap  consisting  of  bone,  deltoid,  etc.,  outwards  and  back- 
wards so  as  so  expose  the  joint  fully. 

Step  5. — Treat  the  joint  secundem  arteni. 

Step  6. — Replace  the  flap.  Wire  the  clavicle.  Close  the  wound  after  pro- 
viding for  drainage. 

The  head  of  the  scapula  is  diseased  or  injured,  the  head  of  the  humerus  is 
unaffected.     Resection  is  required,     v.  Esmarch  operates  as  follows: 

I.  Make  a  curved  incision  around  the  posterior  margin  of  the  acromion 


DISLOCATION    SHOULDER.  969 

and  divide  the  fibres  of  the  deltoid  there  inserted  (Fig.  1 140) .     Expose  the  poste- 
rior and  upper  surface  of  the  joint  capsule. 

2.  From  the  middle  of  the  incision  cut  with  a  knife  down  to  the  postero- 
superior  margin  in  the  head  of  the  scapula,  make  a  longitudinal  incision  through 
the  joint  capsule  between  the  tendons  of  the  supra-  and  infraspinatus  to  the 
middle  of  the  greater  tuberosity.  This  cut  divides  the  skin  and  the  deltoid 
(in  the  direction  of  its  fibres.) 


Fig.  1139. — -{Catterina.) 
I.  Clavicle.  2.  External  third  clavicle.  3.  Coracoid.  4.  Acromion.  5.  Great  tuber- 
osity humerus.  6.  Lesser  tuberosity  humerus.  7.  Clav.  portion  deltoid.  8.  Pectoralis 
major.  9.  Subclavius.  10.  Trapezius.  11.  Pectoralis  minor.  12.  Long  head  biceps. 
13.  Short  head  biceps.  14.  Coraco-brachialis.  15.  Coraco-acromial  ligament.  16.  Cepha- 
lic vein.     17.  Thoracico-acrom.  art.     18.  Suprascap.  nerve.     19.  Suprascap.  art. 

3.  Retract  the  soft  parts.  With  a  periosteal  elevator  separate  the  long 
head  of  the  biceps,  the  articular  capsule  and  the  periosteum  all  together  from 
the  neck  of  the  scapula.  With  a  finger  saw  divide  the  neck  of  the  scapula 
and  remove  the  glenoid  cavity. 

4.  Closed  the  wound  after  providing  drainage. 

When  a  shoulder  dislocation  has  remained  unreduced  for  even  a  compara- 
tively short  time,  the  head  of  the  humerus  becomes  adherent  to  its  surroundings. 
In  subcoracoid  and  subglenoid  dislocations  the  vessels  and  nerves  are  stretched 
directly  over  the  head  of  the  bone,  and  as  they  are  liable  to  become  adherent 
to  the  bone  it  is  easy  to  see  how  dangerous  vigorous  efforts  at  manual  reduction 


970 


SHOULDER. 


may  become.  This  constitutes  the  main  danger  in  manipulative  reduction, 
the  main  difficulties  arise  (a)  from  the  adhesions ;  (b)  shortening  of  the  muscles 
and  tendons  inserted  in  the  tuberosities;  (c)  contractions  and  alterations  of 
the  capsule  which  may  fill  up  the  glenoid  cavity;  (d)  changes  in  the  glenoid 
cavity  due  to  chipping  of  its  border  and  such  like  lesions;  (e)  in  a  case  operated 
on  by  Tully  Vaughan  bony  material  was  found  occupying  the  glenoid  cavity. 
This  bony  material  consisted  of  a  detached  greater  tuberosity  which  was 
adherent  to  the  margins  of  the  glenoid  cavity,  the  floor  of  which  was  smooth 
and  unchanged. 

Cheyne  and  Burghard  lay  down  the  rule  that  it  is  not  advisable  to  attempt 
the  reduction  of  a  subcoracoid  or  subglenoid  dislocation 
after  four  or  five  weeks  have  elapsed  from  the  time  of 
injury,  and  that  it  is  practically  unjustifiable  to  attempt 
it  after  seven  weeks.  Even  within  the  period  mentioned 
any  attempts  at  reduction  must  be  made  with  extreme 
care,  as  rupture  of  the  axillary  artery  has  resulted  from 
attempts  to  reduce  a  dislocation  of  four  weeks'  standing. 
Operations  for  reducing  (so-called  irreducible)  dis- 
locations of  the  shoulder  may  be  roughly  classified  as 
follows: 

I.  Subcutaneous  myotomy  or  tenotomy. 
II.  Osteotomy. 

III.  Arthrotomy  or  arthrotomy  plus  resection. 
IV.  Capsulorrhaphy  (with  or  without  arthrotomy). 
V.  Arthrodesis. 
Subcutaneous   Myotomy   and    Tenotomy. — The 
few  cases  of  reduction  after  the  subcutaneous  division 
of  obstructing  bands  seem  to  have  been  uniformly  successful.     [Unsuccessful 
operations  have  probably  escaped  publication.] 

Weinhold  (1818)  divided  the  pectoralis  major;  Dieffenbach  divided  the  pec- 
toralis  major,  latissimus  dorsi,  teres  major  and  minor,  and  even  some  of  the 
ligaments;  Simon  obtained  recovery  after  seventy  successive  operations  on 
one  patient.  Polaillon  operates  as  follows:  Introduce  a  sharp-pointed  teno- 
tome horizontally  from  without  inwards  to  the  head  of  the  humerus  at  a  point 
one  centimeter  below  the  tip  of  the  acromion.  Guided  by  this  instrument 
introduce  a  long  probe-pointed  tenotome  until  it  penetrates  between  the  anterior 
surface  of  the  head  of  the  humerus  and  the  deltoid.  Remove  the  sharp-pointed 
instrument.  Cutting  against  the  bone  divide  all  obstructing  fibrous  tissues. 
Partially  withdraw  the  tenotome;  reintroduce  it  behind  the  head  of  the  humerus 
and  with  the  same  precautions  divide  all  obstructing  fibrous  bands  there  situated. 
In  similar  fashion  divide  obstructing  bands  in  any  position  around  the  upper 
end  of  the  humerus.  Delay  efforts  at  reduction  for  a  few  days  until  the  ten- 
otomy wound  has  healed.  Molliere  operates  very  similarly,  but  proceeds  to 
manipulative  reduction  as  soon  as  the  tenotome  is  removed.     Forgue  and  Reclus 


Fig.  1 140. — (Esmarch.) 


ARTHROTOMY.  97 1 

recommend  subcutaneous  operation  because  of  its  ease  and  safety.  Cahier 
considers  that  the  operation  possesses  all  the  disadvantages  of  work  done  in 
the  dark,  viz.,  dangers  to  nerves,  vessels,  and  to  the  long  head  of  the  biceps, 
that  it  only  incompletely  divides  obstructing  bands  and  that  it  pays  no  attention 
to  the  fragments  of  bone  torn  from  the  greater  tuberosity  (when  that  is  fractured) 
and  remaining  attached  to  various  tendons.  Most  surgeons  will  agree  with 
Cahier  in  these  conclusions. 

Osteotomy  of  Humerus  for  Irreducible  Dislocation. — In  one  case  J. 
Ewings  Mears  performed  subcutaneous  osteotomy  for  old  subcoracoid  disloca- 
tion. At  first  the  result  was  good,  later  callus,  etc.,  impaired  the  usefulness  of 
the  limb.  In  cases  where  there  are  no  serious  pressure  symptoms  and  owing  to 
age,  debility,  etc.,  the  patient  is  unsuited  to  a  long  operation,  Souchon  proposes 
to  resect  one  inch  of  the  shaft  of  the  humerus  where  it  joins  the  head  and  place 
the  resected  extremity  in  or  near  the  glenoid  cavity.  This  leaves  the  head  in 
abnormal  position,  but,  as  already  noticed,  the  head  is  causing  no  serious 
pressure  symptoms  and  the  patient  is  unfit  for  more  serious  interference. 

Arthrotomy  for  Unreduced  Subglenoid  or  Subcoracoid  Dislocation 
of  the  Shoulder. 

1.  Open  the  joint  by  Ollier's  anterior  incision. 

2.  Retract  the  deltoid  outwards,  the  pectoralis  major  inwards.  This  exposes 
the  head  of  the  bone. 

3.  Examine  the  position  of  the  vessels  and  nerves;  note  if  they  adhere  to 
the  bone;  avoid  injuring  these  structures.  Examine  the  anatomical  neck  of 
the  bone;  divide  the  fibrous  structures  adherent  to  it,  with  a  periosteal  elevator 
detach  them  from  the  head  and  neck  of  the  bone;  keep  the  instrument  against 
the  bone  during  this  work  so  as  not  to  injure  the  vessels  and  nerves. 

4.  Apply  extension  to  the  arm.  With  the  finger  feel  for  bands  obstructing 
reduction;  divide  such. 

5.  Examine  the  glenoid  cavity.  If  it  is  filled  with  fibrous  tissue,  clear  such 
away  by  dissection.  If  the  capsule  is  in  fair  condition,  preserve  it;  if  it  hinders 
reduction,  divide  it,  and  after  reduction  repair  it  by  sutures.  If  the  capsule 
is  in  bad  condition,  i.  e.,  contracted  and  distorted,  dissect  it  away. 

6.  Try  to  reduce  the  dislocation.  This  is  usually  possible.  If,  however, 
reduction  is  still  impossible  examine  with  the  finger  for  the  obstruction.  The 
obstruction  is  commonly  muscular  (supra  and  infraspinatus).  Very  gradually 
separate  these  muscles  at  their  insertion  into  the  great  tuberosity.  Do  not 
separate  them  one  iota  more  than  is  necessary  for  reduction.  Separation  of  the 
subscapularis  from  the  lesser  tuberosity  is  to  be  avoided  if  possible.  Complete 
the  reduction. 

7.  If  sufficient  capsule  remains,  repair  it  by  sutures.  With  sutures  restore 
the  soft  parts,  both  deep  and  superficial,  as  nearly  as  possible  to  their  normal 
condition.  Close  the  wound  with  or  without  drainage.  Dress.  Keep  the 
arm  bound  to  the  side  until  healing  is  complete.  Begin  passive  motion  early, 
using  an  anjesthetic  if  necessary. 


972 


SHOULDER. 


The  operation  is  more  complex  when  there  is  fracture  of  the  neck  of  the 
bone  as  well  as  dislocation  of  the  head.  If  the  head  of  the  bone  is  seemingly 
sufficiently  nourished  reduction  must  be  attempted  by  pushing  and  prying  the 
head  of  the  bone  with  elevators,  forceps,  and  McBurney's  ingenious  hook 
(Figs.  1 141  and  1142).  Free  division  of  resisting  bands  is  of  course  necessary 
After  successful  reduction,  the  fractured  bones  must  be  united  by  suture  (wire, 


Fig.   1 141. — ■{McBurney.) 

chromicized  catgut)  or  by  buried  metallic  splinting.  In  fracture-dislocation  of 
the  humerus  operation  may  be  performed  immediately,  i.  e.,  before  the  lymph- 
atics have  become  clogged  with  debris  in  process  of  removal,  or  late,  i.  e.,  after 
the  lymphatics  have  removed  the  debris  of  destroyed  tissues  and  effused  blood 
and  before  real  attempts  at  repair  of  bone  have  begun. 

As  after-treatment  passive  motion  must  be  begun  early  (about  the  tenth  day). 


Fig.   1142. — (McBiirney.) 


Instead  of  exposing  the  joint  by  means  of  Ollier's  incision  Catterina's  method 
may  be  used. 

Dollinger  ("Zentralblatt  fiir  Chir.,"  Dec.  6,  1902)  in  seven  cases  found 
remarkable  absence  of  callus,  scar  tissue,  etc.  He  operated  with  excellent 
results  in  the  following  manner: 

Step  I. — Incise  from  the  clavicle  to  the  insertion  of  the  pectoralis  major 


DISLOCATION    SHOULDER. 


973 


along  the  inner  side  of  the  cephalic  vein.     Penetrate  the  cleft  between  the  deltoid 
and  the  pectoralis  major  and  expose  the  coracoid  process  (Fig.  1143). 


MDELTOIDEUS 

M.PECT.Mmff 

■N.PECTMAJOR 

mACOBKACHIAUS 
C/IPUrBREmM. 

ejcip/T/s 

VENA  CEPPAUCA 


Fig.   1 143. —  ipollinger.) 

Step  2. — Retract  the  pectoralis  minor  up,  the  coraco-brachialis  out,  and  the 
pectoralis  major  inwards.     Expose  the  bicipital  groove  and  lesser  tuberosity. 
Do  not  injure  the  long  head  of  the  biceps.     The  humeral  head  lies  posteriorly 
and  rotated  somewhat  inwards  (Fig.  1144). 


1"        "^ 

"w 

%.     TUBERCUtmus  ^ 

^\ 

ns^*^^^;^ 

/(^i 

^^jft  M.PECT.  MINOR 

f    JUDEZ-WWEUS-L 

m& 

\    {^t^-CAPUTLONG.M. 

r  *  ///     B/c/Pim 

'■^   V.CEPMALICA  -'  ' 

'^S-Jj-^.SUBSCAPULAR/S 

[              V 

"^TjhM.CORACOBRACH/AUS 
W^M.PECTORAUS  MAJ 

\ 

^^R£mBic/pms' 

\ 

Fig.   1 144. — {Dollinger.) 

Step  3. — Rotate  the  upper  arm  outwards,  thus  bringing  into  the  wound  the 
subscapular  and  the  head  of  the  humerus  covered  by  it  (Fig.  1145). 


974 


SHOULDER. 


Step  4. — Divide  the  tendon  of  the  subscapularis  and  expose  the  head  of  the 
humerus  (Fig.  11 46).  It  is  possible  to  rotate  the  bone  outwards  to  any  extent 
required  and  so  Kocher's  method  of  manipulative  reduction  becomes  easy. 


MPECTMWOR 

~M.S(/SSCAPULA  ■ 
R/S 

f-M.CORACOBRACmUS 
M.PECr.  MAJOR 


Fig.   1 145. —  {Dollinger.) 

According  to  Dollinger,  the  retracted  and  perhaps  sclerosed  subscapularis 
forms  the  obstacle  to  reduction  in  uncomplicated  cases  and  under  it  lies  the  head 
of  the  humerus  in  subcoracoid  dislocation.     If,  as  happened  in  one  of  DoUinger's 


i^^M.P£Cr.M/NOR 

Hp[_^    ^ 

^1 

K^^'^j 

J%m-~~CAPUT  HUMERI 

t^^z/.w-||| 

wm. 

■1            Iwr 

f  M/kSUBSCAPULAR/S 
'^  ».P£Cr.  MAJOR 

^KSACOBmHIALl/y^M 

Fig.   1 146. —  {Dollinger.) 

cases,  reduction  is  impossible  after  section  of  the  subscapular  tendon,  pull  the 
arm  strongly  downwards,  continue  the  split  in  the  tendon  to  the  glenoid  fossa 
and  remove  any  obstruction  present.     Sometimes  reduction  by  arthrotomy 


DISLOCATION   SHOULDER.  975 

proves  impossible.  Under  these  circumstances  decapitation  of  the  humerus 
and  removal  of  the  head  is  proper,  unless  a  new  joint  has  formed  giving  satis- 
factory function.  Uusally  there  is  great  pain  and  disturbance  due  to  pressure 
one  the  vessels  and  nerves.  The  operation  is  essentially  the  same  as  that  for 
reduction  of  the  dislocation,  but  the  head  of  the  bone  is  removed  after  section  of 
its  neck  by  means  of  a  Gigli  wire  saw.  Enough  bone  must  be  removed  to 
insure  a  good  new  joint.  As  an  aid  to  the  making  of  a  new  joint  one  may  cover 
the  divided  end  of  the  humerus  with  the  flap  of  muscle  or,  better,  of  fascia  and 
fat. 

Regarding  excision,  Jonas  writes:  "This  is  an  operation  to  be  avoided 
when  possible,  on  account  of  the  resultant  flail-like  condition  of  the  arm 
and  yet  must  be  done  (a)  when  the  humeral  head  and  neck  become  too  exten- 
sively stripped  of  their  attachments,  experience  having  shown  that  necrosis  may 
occur  in  16  per  cent.  (Souchon)  of  the  cases;  (b)  when  osseous  union  has 
occurred  between  the  head  and  the  ribs;  (c)  when,  after  a  division  of  all  the 
restraining  soft  parts,  the  head  rests  against  the  point  of  the  acromion  process" 
("Annals  Surg.,"  May,  1903). 

In  case  of  osseous  union  between  the  head  of  the  humerus  and  the  ribs  it 
would  seem  to  the  author  better  when  possible  to  divide  this  union,  trim  away 
irregularities  from  the  head  of  the  bone,  cover  it  with  a  pedunculated  flap  of 
fat  and  fascia  and  reduce  it,  thus  forming  a  new  joint  with  the  minimum  loss 
of  substance. 

In  his  classical  paper  on  irreducible  shoulder  dislocations  ("Transactions 
Am.  Surg.  Assoc,"  1897)  Souchon  comes  to  the  following  conclusions  regarding 
anterior  displacements:  "The  anterior  incision  is  the  route.  Reduction  is 
the  more  desirable  operation,  because  it  preserves  the  head  and  all  the  move- 
ments depending  thereon.  Reduction  should  be  done  only  in  cases  where 
the  head  and  glenoid  cavity  are  in  good  condition ;  when  no  extensive  dissections 
have  to  be  madfe;  when  it  is  easily  effected  without  any  great  efifort;  when  the 
head  does  not  need  to  be  trirnmed  or  the  cup  to  be  too  deeply  scooped  or  en- 
larged; when  the  head  readily  remains  in  place,  but  not  too  tightly.  All  this 
regardless  of  the  time  or  standing  of  the  dislocation.  It  should,  however, 
always  be  attempted  conscientiously,  because  many  have  resected, 
perhaps,  when  the  dislocation  could  have  been  reduced.  Disregard  of  these 
rules  may  result  in  necrosis  of  head,  in  recurrence  of  the  dislocation  or  in 
anchylosis,  with  their  inevitable  consequences.  Resections  should  be  practised 
in  all  other  cases.  When  in  doubt  it  is  preferable  to  resect.  How  much  to 
resect,  i.  e.,  whether  to  saw,  through  the  anatomical  neck,  or  obliquely  and 
downwards  outside  the  tuberosity,  or  horizontally  on  a  level  with  the  lower 
margin  of  the  head,  must  be  determined  in  each  case;  it  is  best  to  remove  too 
much  than  too  little."  The  last  remarks  of  Souchon  require  some  modifica- 
tion. In  subjects  under  eighteen  years  of  age  it  is  most  important  not  to 
injure  the  epiphyseal  cartilage  between  the  head  and  the  shaft  (Fig.  1147). 
"A  horizontal  section  with  the  saw,  starting  at  the  internal  insertion  of  the 


976 


SHOULDER. 


capsule  around  the  head,  will  surely  carry  away  the  totality  of  the  conjugating 
cartilage.  In  young  children,  if  the  resection  is  made  below  the  epiphyseal 
cartilage,  the  arm  will  cease  to  grow.  The  resected  extremity  should  not  be 
pushed  into  the  glenoid  cavity  in  children,  lest  the  growth  of  bone  cause  anchylo- 
sis" (Souchon). 

Posterior  or  Subspinous  Dislocation  Shoulder. — These  dislocations 
are  commonly  congenital.  Scudder's  rule  for  distinguishing  between  the 
congenital  and  traumatic  varieties  is  that  in  the  former  the  scapula,  clavicle 
and  arm  bones  are  not  so  well  developed  as  on  the  sound  side.  Only  a  few 
operations  have  been  performed  for  "irreducible"  dislocations  of  the  above 


Unites  with  the  shaft  at  the  twentieth  year 
The  upper  epiphysis  is  formed  by  the  union  of  the 
nucleus  for  the  head,  greater  tuberosity,  and 
that  for  the  lesser  tuberosity.  These  form  a 
common   epiphysis    before  uniting  with    the   shaft 

Capsular  line 


Shaft  begins  to  ossify  in  the  eighth  week  of 
intra-uterine  life 

Fig.   1147. — {Morris.) 
Ossification  of  the  humerus;  the  figure  also  shows  the  relations  of  the  epiphyseal  and 

capsular  lines. 


kind  and  of  these  Phelps's  operation  seems  to  have  given  the  best  results. 
Phelps's  operation  is  thus  described  in  Souchon's  monograph:  "Curved 
incision  along  the  lower  edge  of  the  deltoid  and  on  to  the  scapula,  and  flap 
turned  down;  it  would  be  best  to  curve  the  incision  downwards  and  turn  the 
flap   upwards,  as  it   would  give   better   drainage. 

Difficulties  and  complications  of  the  operation:  The  posterior  edge  of 
the  glenoid  cavity  was  gone  and  the  cavity  was  about  two-thirds  the  normal 
size;  a  portion  of  the  head  of  the  humerus  was  cut  away  in  order  to  fit  it  to  the 
socket;  also  cut  away  a  portion  of  the  redundant  capsule  posteriorly;  the  bone 
replaced  and  a  stitch  put  in  behind  to  help  retain  the  head  in  place. 

Complications  after  the  operation:  None.  Result  immediate:  Drainage- 
tube  left  a  week.     Result  remote:     Is  satisfactory.     Dr.  A.  P.  Dudley  saw 


FRACTURE   DISLOCATION.  977 

the  patient  a  year  after  the  operation,  and  there  was  a  little  difference  between 
the  two  arms.  Remarks:  Dr.  Dudley  did  not  doubt  that  the  injury  had 
occurred  during  delivery.  Doctors  who  had  seen  the  patient  before  were  of 
the  opinion  that  it  was  one  of  paralysis.  Dr  A.  M.  Phelps  says  that  the  method 
promised  success  during  the  first  year,  although  one  case  has  been  operated 
in  which  it  was  successful  at  the  fifth  year." 

In  another  case  in  which  reaction  of  degeneration  was  present,  apparently 
due  to  pressure  neurosis,  the  result  obtained  by  Phelps  was  not  so  perfect, 
but  the  reaction  of  degeneration  disappeared. 

Peckham  ("Am.  Journ.  Orthopedic  Surg.,"  April,  1905)  reports  two  cases 
in  which  he  obtained  improvement  by  means  of  Phelps's  procedure. 

Dislocation  plus  Fracture  of  the  Head  of  the  Humerus. — In  117  cases 
of  the  above  injury  the  fracture  was  located  at  the  surgical  neck  in  sixty-nine, 
at  the  anatomical  neck  in  twenty-seven,  at  the  "neck"  in  eleven,  at  both 
surgical  and  anatomical  necks  in  six;  one  case  was  comminuted,  and  the 
"upper  part"  of  the  humerus  was  fractured  in  three  (McBurney  and  Dowd). 
In  the  aged,  the  feeble,  and  perhaps  in  diabetics  and  some  nephritics,  etc., 
it  is  wise  to  adopt  Riberi's  treatment  provided  that  the  head  of  the  bone  is  not 
giving  rise  to  pain  and  other  pressure  symptoms.  This  treatment  (Riberi's) 
consists  of  massage  and  passive,  later,  active  motion,  and  aims  at  the  production 
of  a  pseudarthrosis.  In  all  other  cases  more  active  treatment  is  necessary. 
Never  fail  in  recent  cases  to  attempt  reduction,  under  an  anaesthetic,  by  means 
of  manipulation  and  finger  pressure  applied  to  the  dislocated  head  of  the 
humerus.  This  is  occasionally  successful  and  the  condition  becomes  one  of 
mere  fracture.  Never  attempt  reduction  by  any  of  the  manipulations  suitable 
in  uncomplicated  dislocation.  It  is  wise  to  be  prepared  to  proceed  at  once  to 
arthrotomy  if  simpler  means  fail. 

Arthrotomy  for  Fracture-dislocation  of  the  Humerus. — McBurney's 
Operation. — Make  an  incision  about  i  1/2  inches  long  about  i  inch  below 
the  acromion.  Penetrate  the  deltoid  to  the  outer  surface  of  the  upper  fragment. 
Drill  a  hole  through  the  upper  fragment  horizontally.  (This  supposes  fracture 
at  or  near  the  surgical  neck.)  Into  the  perforation  fit  the  right-angled  beak 
of  McBurney's  traction  hook  (Figs.  1141  and  1142).  Make  traction  on  the 
upper  fragment  by  means  of  the  hook  and  at  the  same  time  press  with  the  fingers 
on  the  head  of  the  bone  and  so  reduce  it.  Treat  the  fracture  secundem  artem. 
Farquhar  Curtis  has  found  McBurney's  hook  tear  out  during  the  necessary 
traction  but  by  using  leverage  with  a  periosteal  elevator  and  by  dividing 
obstructing  bands  he  succeeded  in  obtaining  reduction. 

Schlange's  Operation.— ("  Archiv.  fur  klin.  Chir.,"  Ixxxi,  II.  Theil). 
Abduct  the  arm.  Make  a  4  1/2  inch  incision  along  the  axillary  margin  of  the 
pectoralis  major  and  coraco-brachialis.  Retract  these  two  muscles  forwards, 
retract  the  axillary  vessels  and  nerves  backwards  and  protect  them.  Incise  the 
joint  capsule  or  enlarge  (if  necessary)  any  tear  which  may  involve  the  capsule  and 
so  expose  the  heads  of  the  bone.  Remove  any  splintered  fragments  of  bone. 
62 


978  SHOULDER. 

Reduce  the  dislocated  humeral  head  by  direct  manipulation  with  the  fingers  and 
by  prying  with  blunt  instruments.  Schlange  operated  in  this  manner  on  one  case 
of  fracture  of  the  anatomical  and  in  one  of  the  surgical  neck.  In  the  former  case 
the  question  of  resection  presented,  as  the  head  of  the  bone  was  separated  from 
almost  all  its  connections;  "the  good  result  obtained  demonstrates  that  one 
dare  to  and  ought  to  act  very  conservatively  just  as  in  the  case  of  a  dislocated 
astragalus."  This  advice  of  Schlange's  is  good  when  the  patient  is  in  the 
hands  of  a  first  class  surgeon  and  in  proper  surroundings,  but  there  are  circum- 
stances in  which  resection  is  much  safer  and  will  give  an  excellent  functional 
result,  especially  if  the  upper  end  of  the  humerus  be  covered  with  Murphy's 
flap  of  fatty  fibrous  tissue. 

Arthrodesis  Shoulder. — When,  as  a  result  of  paralysis,  the  shoulder- 
joint  becomes  flail-like  and  yet  the  muscles  of  the  elbow  and  of  the  hand  and 
those  uniting  the  scapula  to  the  trunk  are  not  paralyzed,  the  operation  of 
arthrodesis  may  be  useful.  If  the  elbow  muscles  are  also  paralyzed  but  those 
for  the  hand  remain  active,  artificially  produced  anchylosis  (arthrodesis)  of 
both  shoulder  and  elbow  may  be  of  service. 

Step  I. — Exposure  of  the  joint.  Owing  to  the  degeneration  of  the  deltoid 
and  of  the  circumflex  nerve  in  cases  of  paralytic  luxation  it  is  useless  to  pay 
much  attention  to  these  structures,  hence  incision  may  be  made  where  conven- 
ient ("Bothezat,  Rev.  de  Chir.,"  June,  1901). 

From  a  point  a  little  internal  to  the  acromio-clavicular  joint  make  an 
incision  downwards  to  the  outer  side  of  the  pectoro-deltoid  groove  for  a  distance 
of  2  1/2  to  4  inches. 

Step  2. — The  deltoid  being  practically  absent,  it  is  very  easy  to  open  the 
joint  by  cutting  the  capsule  along  the  bicipital  groove. 

Step  3. — Excise  as  much  of  the  synovialis  as  possible  and  scrape  with  the 
spoon  every  accessible  part  of  the  remainder. 

Step  4. — Push  the  head  of  the  humerus  out  of  the  wound.  This  is  easy 
because  all  the  tissues  are  relaxed  and  the  muscles  paralyzed.  Remove  all 
cartilage  from  the  head  of  the  bone.  Vivify  the  glenoid  cavity  by  removing 
the  cartilage.     Vivify  an  appropriate  surface  of  the  acromion  process. 

Step  5. — Let  an  assistant  steady  the  scapula  in  good  position.  Place  the 
humeral  head  in  contact  with  the  glenoid  cavity  and  the  acromion  process. 
The  most  useful  position  (Bothezat)  is  one  of  slight  internal  rotation  with  the 
arm  at  an  angle  of  45°  to  the  external  border  of  the  scapula.  Fix  the  bone  in 
position  by  means  of  two  wires,  one  uniting  the  humerus  to  the  upper  part 
of  the  glenoid,  the  other  uniting  the  humerus  to  the  acromion. 

Step  6. — Close  the  wound  by  deep  and  superficial  sutures,  being  careful 
to  "take  up  the  slack"  in  the  capsule.  Immobilize.  After  the  wound  has 
completely  healed  treat  the  muscles  by  means  of  massage  and  elecrical  stimu- 
lation, but  keep  up  immobilization  for  two  months,  i,  e.,  until  consolidation 
has  had  time  to  take  place. 


HABITUAL   DISLOCATION.  979 

Habitual  Dislocation  Shoulder. — Burrell  operates  by  excising  a  portion 
of  the  capsule  in  the  following  manner: 

Make  Ollier's  anterior  incision. 

Expose  the  coraco-brachialis,  short  head  of  the  biceps,  and  upper  part  of 
the  tendon  of  the  pectoralis  major  below;  divide  the  upper  three-fourths  of 
the  tendon  of  the  pectoralis  major  at  its  insertion  and  so  expose  the  head  of  the 
humerus  and  part  of  its  shaft. 

Rotate  the  arm  outwards  and  push  the  elbow  a  little  backwards,  exposing 
the  tendon  of  the  subscapularis  stretched  over  the  head  of  the  bone.  Divide 
the  upper  portion  of  this  tendon.  Abduct  the  arm  to  an  angle  of  45°;  press  the 
head  of  the  bone  backwards  so  as  to  relax  the  capsule  anteriorly.  Excise  a 
strip  of  capule  about  3/4  inch  long  by  3/8  inch  wide.  Suture  the  wound  in  the 
capsule.  Close  the  wound.  Dress.  Immobilize.  A.  I.  Mackinnon  improves 
Burrell's  operation  by  avoiding  excision  of  the  capsule  and  by  closing  the 
wound  in  an  overlapping  fashion.  The  operation  consists  "in  doing  an  open 
arthrotomy;  the  muscles  are  well  retracted  and  the  capsule  is  opened  from 
the  coracoid  process  downwards.  Mattress  sutures  are  introduced  i  to  i  1/2 
inches  from  one  margin  of  the  incision  in  such  a  manner  that  when  they  are 
tied  one  flap  slides  under  the  other.  By  this  process  there  is  a  double  layer 
of  capsule  over  what  is  ordinarily  the  weakest  point,  and  increased  protection 
against  recurrence  is  given  the  joint.  A  running  suture  closes  the  exposed 
margin  of  the  capsule,  and  the  external  w'ound  is  closed  in  the  usual  manner." 
In  similar  cases  Robert  Jones  often  cuts  down  to  but  not  into  the  capsule; 
seizes  the  capsule  with  two  forceps,  twists  it  tight  and  with  sutures  fixes  the 
folded  or  twisted  capsule  so  that  it  cannot  relax. 

Turner  Thomas  ("Journal  A.  M.  A.,"  March  12,  1910)  performs  capsulor- 
rhaphy  through  an  incision  in  the  axilla. 

Step  I. — Make  a  cut  in  the  axilla  along  the  coraco-brachialis  muscle  from 
the  side  of  the  chest  downwards  for  about  5  inches.  Retract  outwards  the 
coraco-brachialis,  biceps  and  pectoralis  major.  Retract  inwards  the  axillary 
vessels  and  nerves  as  well  as  the  musculo-cutaneous  nerve.  Doubly  ligate 
and  divide  the  anterior  circumflex  vessels  and  expose  the  latissimus  dorsi  in 
the  floor  of  the  wound.  Locate  and  protect  the  circumflex  nerve  and  the 
posterior  circumflex  vessels  as  they  pass  backw^ards.  On  a  grooved  director 
divide  about  half  the  width  of  the  subscapular  muscle,  thus  exposing  the  capsule. 

Step  2. — Open  the  capsule  by  a  cut  about  i  1/2  inches  in  length,  in  the 
line  of  the  anterior  glenoid  margin  and  about  1/2  inch  below  it.  Explore  the 
joint  for  any  obstruction  to  reduction. 

Step  3. — Close  the  wound  in  the  capsule  by  the  overlapping  method.  Repair 
the  wound  in  the  subscapularis.  Close  the  wound.  Bind  the  arm  to  the  side 
and  support  the  wrist  in  a  sling. 

After-treatment. — On  the  ninth  day  the  patient  may  put  his  arm  through 
the  sleeve  of  his  coat.  For  three  weeks  keep  the  arm  bound  to  the  chest  during 
the  night.     After  which  time  forcible  movements  may  be  begun.     Thomas  finds 


98o 


SHOULDER. 


that  patients  become  able  to  raise  their  arms  straight  above  their  heads  in  from 
six  to  fifteen  weeks  after  operation. 

Perthes  ("Deutsche  Zeitschrift  fiir  Chir.,"  Ixxxv)  believes  habitual  disloca- 
tion of  the  shoulders  is  generally  due  to  fracture  of  the  upper  end  of  the  humerus 
or  of  the  scapula.  Ov^^ing  to  muscular  action  or  to  direct  violence  the  greater 
tuberosity  is  often  fractured  or  the  tendons  give  way  near  their  insertion  there, 
and  are  likely  to  unite  to  the  capsule.  In  other  cases  the  glenoid  may  be  injured, 
giving  rise  to  foreign  bodies  in  the  joint.  Sometimes  the  trouble  is  due  to 
relaxation  or  rupture  of  the  capsule.  The  capsule  is  normally  so  large  that 
it  is  capable  of  holding  two  humeral  heads  or  of  permitting  subcoracoid  dis- 
location (Perthes).  It  may  be  enlarged  uniformly  or  the  anterior  part  may 
be  enlarged  and  form  a  sort  of  hernia. 

In  operating  always  open  the  joint  to  look  for  damage  to  the  bones  and 
tendons.  If  the  tuberosity  is  fractured  or  the  tendons  torn  off  from  it,  the 
injury  must  be  repaired,  or  the  joint  will  not  be  secure.  The  best  method  of 
joining  the  ruptured  tendons  to  the  bone  is  by  double-pointed  steel  tacks 
(Perthes)  which  are  either  driven  through  the  tendons  into  the  bone  or  are  first 
driven  into  the  bone  and  the  tendons  then  sutured  to  them.  The  glenoid 
ligament  may  be  fastened  to  the  neck  of  the  scapula  in  the  same  fashion. 
Perthes  exposes  the  joint  by  turning  backwards  and  upwards  a  flap  of  skin 
and  of  the  whole  deltoid  muscle.     This  exposes  the  joint  very  well  and  the 

muscles  is  said  not  to  suffer  from  the  disinsertion, 
if  sewed  in  place  firmly.  The  joint  may  be  reached 
from  in  front  by  an  incision  along  the  border  of  the 
deltoid,  the  anterior  portion  of  which  is  severed 
near  the  clavicle.  The  tendon  of  the  pectoralis 
major  is  cut  and  this  muscle  is  drawn  towards  the 
breast.  The  end  of  the  coracoid  process  is  removed 
with  a  Gigli  wire  saw  and  the  coraco-brachialis  and 
short  head  of  the  biceps  drawn  down.  The  upper 
])order  of  the  subscapularis  may  be  drawn  back  or 
severed.  After  suturing  the  tendons  of  the  scapular 
muscles  and  repairing  the  glenoid  ring,  the  capsule  is  drawn  up  with  sutures 
so  placed  as  to  strengthen  it.  The  muscles  cut  during  the  operation  are  then 
restored  and  the  skin  closed. 

Arthroplasty  of  Shoulder. — The  general  principles  governing  the  opera- 
tion of  arthroplasty  are  described  on  page  927. 

Step  I. — Expose  the  joint  through  OUier's  incison. 

Step  2. — Overcome  the  anchylosis.  In  bony  anchylosis  resection  and 
modelling  of  the  head  of  the  humerus  will  be  necessary.  See  that  motion  is 
even  more  than  normally  free. 

Step  3. — Method  A. — Through  an  incision  parallel  to  its  fibres,  expose  the 
surface  of  the  middle  portion  of  the  pectoralis  major.  Mobilize  a  flap  from 
the  pectoralis  major,  the  pedicle  of  the  flap  being  formed  by  its  humeral  inser- 


FlG.  1148.— (Pavr.) 


ARTHROPLASTY.  98 1 

tion  (Fig.  1 148,  Payr).  Make  a  subcutaneous  tunnel  from  the  wound  on  the 
chest  to  that  opening  the  joint  and  pull  the  pectoral  flap  through  the  tunnel 
into  the  joint.  Wrap  the  flap  over  the  head  of  the  humerus  and  fix  it  in 
position  by  a  few  sutures. 

Method  B. — Exactly  the  same  as  method  A  but  the  flap  is  formed  of  the 
fat  and  fascia  covering  the  pectoralis  major  instead  of  muscular  tissue. 

Method  C. — Carefully  wrap  the  head  of  the  bone  in  Baer's  membrane 
(see  p.  930). 

Step  4. — Close  the  wounds.     Apply  dressings. 


CHAPTER  XCIV. 

CLAVICULO-HUMERAL  NEARTHROSIS. 

It  is  interesting  and  valuable  to  know  that  a  useful  new  joint  can  be 
established  after  excision  of  the  scapula  and  of  the  upper  end  of  the  humerus 
even  when  a  useless  flail-like  articulation  has  been  present  for  a  long  time. 
Ollier's  case  presents  so  many  points  of  interest  and  his  treatment  of  it  is  so 
suggestive  in  many  ways  that  no  apology  is  necessary  for  discussing  it  at  some 
length. 


Fig.  1 149. — (Oilier.) 

The  patient  was  wounded  in  the  shoulder  in  187 1.  He  subsequently 
underwent  many  operations — sequestrotomies,  typical  resection  of  the  humeral 
head,  complete  removal  of  the  scapula,  etc.,  etc.  ("Revue  de  Chir.,"  July 
1899).  Figure  1149  shows  the  appearance  of  the  patient.  The  outer  end  of 
the  clavicle  was  pulled  upwards  by  the  trapezius  and  was  connected  with  the 

982 


OLLIER  S    OPERATION. 


985 


humerus  merely  by  skin,  fibrous  tissue,  and  some  atrophied  bands  of  muscle. 
The  arm  itself  drooped  because  of  its  own  weight.  The  limb  was  useless 
though  the  muscles  of  the  forearm  and  hand  were  well  nourished.  The  upper 
end  of  the  humerus  was  thin,  pointed,  surrounded  by  scar  tissue,  and  about 
2  3/4  inches  distant  from  the  clavicle.  The  muscles  of  the  shoulder  were  so 
atrophied  that  only  with  difficulty  could  remnants  of  them  be  found  among 
the  scars  of  the  incisions  existing  where  the  scapula  had  been.  The  deltoid 
had  lost  all  its  clavicular  connections  except  its  inner  fibres  which  were  stretched 
and  atrophied.     The  rest  of  the  deltoid  had  retracted  to  its  lower  insertion, 


Fig.   1 150. — {Oilier.) 


curling  itself  up  in  a  bunch  over  the  upper  end  of  the  humerus.     The  pectoralis 
major  formed  the  principal  support  of  the  arm. 

Oilier  operated  as  follows: 

(i)  Antero-lateral  incision  from  the  outer  end  of  the  clavicle  downwards. 

(2)  Vivification  of  the  under  surface  of  the  clavicle  for  an  area  of  about 
I  1/2  square  inches.     This  was  done  by  turning  aside  a  flap  of  periosteum. 

(3)  Extension  of  the  incision  sufficiently  to  permit  the  formation  of  a 
cavity  through  which  the  humerus  could  be  brought  into  contact  with  the 
clavicle  (care  was  here  required  to  avoid  injuring  the  vessels  and  nerves.     It 


984  CLAVICULO-HUMERAL  NEARTHROSIS. 

was  necessary  to  excise  some  of  the  scar  tissue  before  the  humerus  could  be 
brought  into  proper  position. 

(4)  Cutting  ofif  the  pointed  extremity  of  the  humerus  in  order  to  obtain  a 
surface  large  enough  to  unite  to  the  clavicle.  When  removing  the  bone  Oilier 
preserved  its  periosteum. 

(5)  Drilling  of  two  holes  through  the  clavicle  and  two  holes  (from  before 
backwards)  through  the  humerus.     Wiring  of  the  humerus  to  the  clavicle. 

(6)  Suture  of  the  periosteum  of  the  humerus  to  that  of  the  clavicle  {i.  e., 
the  reflected  flaps  of  periosteum). 

(7)  Dissection  and  straightening  out  of  the  periarticular  muscles  so  that 
they  could  be  sutured  where  they  would  do  most  good,  e.  g.,  the  deltoid  which 
was  curled  up  on  itself  was  freed  from  adhesions  and  then  sutured  to  the 
trapezius  which  was  separated  from  the  clavicular  insertion;  such  portions 
of  the  deltoid  as  did  not  correspond  to  portions  of  the  trapezius  were  sutured 
to  the  periosteum  and  tissues  around  the  clavicle. 

(8)  Closure  of  the  wound.  The  limb  was  immobilized  for  four  months, 
but  during  that  time  the  deltoid  was  stimulated  by  electricity  applied  through 
a  window  cut  in  the  dressings.  After  the  above  time  no  bony  union  had  taken 
place.  In  time  a  useful  and  movable  joint  formed.  Figure  1150  shows  the 
patient  twenty-five  months  after  operation. 


CHAPTER  XCV. 

SUBACROMIAL  OR  SUBDELTOID  BURSITIS. 

Codman's  Bursitis  is  more  common  than  any  other  lesion  of  the  shoulder 
or  inflammation  of  any  other  bursa.  Normally,  a  bursa  exists  between  the 
deltoid  and  acromion  and  the  short  rotators  which  form  the  capsule  of  the 
shoulder.  When  the  arm  hangs  at  rest  a  small  portion  of  the  bursa  extends 
under  the  acromion  process  and  the  coraco-acromial  ligament.  When  the  arm 
is  abducted  the  base  of  the  bursa  which  is  on  the  tuberosity  of  the  humerus 
passes  upwards  under  the  acromion  and  the  coraco-acromial  ligament.     When 


Fig.   1 151. — {Codman.) 

bursitis  is  present  abduction  and  likewise  external  rotation  become  impossible. 
In  chronic  inflammation  the  normally  thin  and  pliable  bursal  walls  become 
thickened,  and  if  simpler  means  of  treatment  fail,  excision  becomes  necessary. 

The  Operation. — Step  i. — From  a  point  midway  between  the  coracoid 
and  the  acromion  make  a  2  to  2  1/2  inch  incision  parallel  to  the  fibres  of  the 
deltoid  (Fig.  1151).  Split  the  deltoid  and  enter  the  bursa  as  if  it  were  the 
peritoneum. 

Step  2. — Excise  the  adherent  or  thickened  portion  of  the  bursa. 

Step  3. — Attend  to  hemostasis.  Close  the  wound  in  the  deltoid  with  fine 
catgut  sutures.  Close  the  skin  wound.  Apply  dressings.  Begin  motion  in 
about  ten  days. 

985 


CHAPTER  XCVI. 
ELBOW. 

INTRAARTICULAR  INJECTION. 

The  technic  of  intra-articular  injections  has  been  so  fully  treated  elsewhere 
that  it  is  sufficient  to  mention  the  point  of  puncture  of  the  elbow-joint.  Recog- 
nize by  palpation  the  head  of  the  radius.  From  the  outer  side  of  the  arm 
introduce  a  trocar  at  right  angles  to  the  long  axis  of  the  limb,  immediately 
above  the  radial  head,  and  penetrate  into  the  joint. 

Resection  or  Excision  of  the  Elbow.  Posterior  Vertical  Median 
Incision. — Step  i. — Have  an  assistant  hold  the  arm  firmly  in  a  position  of 
partial  flexion.  Make  a  longitudinal  incision  from  a  point 
2  inches  above,  to  a  point  2  inches  below,  the  tip  of  the 
olecranon  (Fig.  1152).  The  cut,  following  the  middle  line 
of  the  olecranon  and  lower  part  of  the  humerus,  penetrates 
at  once  to  the  bone  and  opens  the  posterior  part  of  the  joint. 
Step  2. — With  a  periosteal  elevator  or  knife  separate 
all  the  soft  parts  (including  periosteum  and  inner  portion 
of  triceps  tendon)  from  the  olecranon  process  on  the  inner 
side  of  the  vertical  wound.  In  doing  this,  if  one  uses  the 
knife,  one  must  strongly  retract  the  tissues  inwards  with 
the  nail  of  his  left  thumb  and  cut  with  short  decided  move- 
ments of  the  knife  on  to  the  bone.  As  such  a  manner  of 
cutting  is  essential,  but  soon  renders  the  knife  as  blunt  as 
the  proverbial  ploughshare,  it  is  well  to  have  several  knives 
prepared.  In  all  the  cutting  practised  in  resection  of  the 
elbow  the  edge  of  the  knife  must  be  directed  against  the  bone 
Fig.  1152.  (Fig.   1153). 

Continue  the  separation  inwards  until  not  only  is  the 
inner  part  of  the  olecranon  bare  of  covering,  but  the  same  is  true  of  the 
inner  part  of  the  lower  end  of  the  humerus  and  the  internal  epicondyle  can 
be  protruded  into  the  wound. 

The  ulnar  nerve  lying  in  the  groove  between  the  olecranon  and  the  internal 
condyle  is  raised  up  and  retracted  inwards  with  the  rest  of  the  soft  structures 
(Fig.  1 1 54).  It  should  not  be  seen.  The  structures  on  the  outer  side  of  the 
elbow  are  to  be  treated  in  the  same  way  as  those  on  the  inner  side.  The 
manoeuvres  described  effect  a  complete  decortication  of  the  posterior  and 
lateral  surfaces  of  the  bones  forming  the  elbow. 

986 


EXCISION. 


987 


Step  3. — Flex  the  elbow  completely.  Push  the  lower  end  of  the  humerus 
out  of  the  wound  and  separate  it  from  the  soft  structures  in  front  to  the  desired 
extent.  With  a  flat  piece  of  metal  (retractor  or  spatula)  protect  the  soft  parts 
in  front  of  the  elbow.  Seize  the  lower  end  of  the  humerus  with  lion-jawed 
forceps  and  remove  with  a  saw  as  much  of  it  as  seems  desirable  (Fig.  1155) 
Any  operating  saw  is  suitable.  (Some  surgeons  use  a  butcher's  saw  with  its 
sawing  edge  turned  towards  the  bow  of  the  instrument.  The  sawing  ribbon 
is  placed  in  front  of  the  bones  while  the  bow  is  behind  them,  the  bone  is  sawn 
through  backwards,  and  all  danger  to  the  vessels  anterior  to  the  joint  is 
averted.) 

With  the  elbow  still  flexed,  make  the  upper  ends  of  the  radius  and  ulna 
protrude  through  the  wound  and  saw  them  off  with  the  same  precautions. 

Step  4. — Review  the  wound  to  see  if  all  osteal  disease  has  been  removed. 
Any  diseased  synovialis  which  may  be  seen  must  be  cautiously  and  thoroughly 
removed  by  dissection. 


Fig.   1 153. — {Schwartz.) 


Fig.   1154. — {Schwartz.) 


How  much  bone  ought  to  be  removed?  The  line  of  section  of  the  ulna 
should  permit  removal  of  the  greater  and  lesser  sigmoid  cavities  with  the 
olecranon.  The  radius  should  be  divided  at  the  same  level  just  below  its  head, 
above  the  biceps.  Jacobson  writes,  regarding  section  of  the  humerus:  "An 
insuflicient  amount  is  usually  removed  here,  and  limitation  of  subsequent 
movement  thereby  invited.  It  is  generally  considered  sufficient  to  remove 
all  the  articular  cartilage,  the  section  being  made  to  pass  through  the  lower 
part  of  the  coronoid  and  olecranon  fossae,  and  below  the  level  of  the  epitrochlea 
on  the  inner,  and  through  the  epicondyle  on  the  outer  side.  This  is  not  enough. 
The  saw  should  pass  at  a  higher  level,  i.  e.,  above  the  level  of  the  epicondyle, 
and  through  the  highest  part  of  the  epitrochlea,  removing  quite  the  lower 
two-thirds  of  this  process.     This  is  the  very  lowest  level  at  which  the  surgeon 


988 


ELBOW. 


should  hold  his  hand  if  he  desires  to  obtain  good  movement.  And  before  he 
is  satisfied  on  this  point  he  should  place  the  fingers  of  the  affected  limb,  not 
only  on  the  opposite  shoulder  and  mouth  (as  is  often  done),  but  on  the  shoulder 
of  the  same  side,  and  behind  the  back  to  the  angle  of  the  opposite  scapula. 
Unless  these  movements  are  perfectly  free,  he  should  take  another  thin  slice 
off  the  humerus,  removing  the  whole  epitrochlea.  This  step  may  seem  to 
my  younger  readers  a  needless  shortening  of  the  limb,  and  likely  to  lead  to  a 
flail-joint.  I  can  assure  them  that  it  is  not  so.  As  long  as  the  elbow-joint 
is  freely  movable,  shortening  of  the  bones  matters  very  little.  If  attention 
has  been  paid  to  the  advice  given  and  the  soft  parts  separated  very  carefully 


Fig.  1155. 

and,  as  far  as  possible,  subperiosteally  from  the  epicondyle  and  epitrochlea, 
the  joint  will  become  sufficiently  steady  laterally  as  well  as  freely  movable, 
although  these  bony  prominences  have  been  freely  removed.  Another  test 
which  the  surgeons  should  always  apply  before  considering  the  section  of  the 
bones  completed  is  the  interval  between  the  sawn  ends.  Prof.  Annandale 
considers  that  i  1/2  inches  should  intervene  between  them  when  the  bones 
are  extended."  This  valuable  advice  of  Jacobson  does  not  apply  when  one 
covers  the  sawn  surfaces  of  the  bone  with  a  flap  of  fascia  and  fat.  If  the 
operation  has  been  undertaken  for  tuberculosis,  rub  iodoform  into  all  raw  sur- 
faces. Suture.  Provide  drainage.  Dress.  As  an  alternative,  fill  the  wound 
cavity  with  iodoform  emulsion  or  its  equivalent  and  close  without  drainage. 
It  is  generally  recommended  to  place  the  partially  flexed  limb  in  a  metal  splint 


EXCISION. 


989 


provided  with  an  adjustable  joint  opposite  tlie  elbow.  The  young  surgeon, 
especially  in  the  country-,  will  generally  be  without  such  apparatus,  but  in 
the  author's  experience  a  starch  or  light  plaster  bandage  strengthened  with 
strips  of  pasteboard  or  wire  netting  answers  all  purposes.  The  after-treatment 
is  the  same  as  that  described  in  the  chapter  on  the  operative  treatment  of 
old  dislocations  of  the  elbow. 

Kocher's  Method. — Kocher  is  true  to  his  principle  that  in  arthrectomy 
it  is  far  better  to  make  a  complicated  skin  incision  than  a  simple  one,  if  by  so 
doing  one  can  preserve  intact  not  merely  the  muscles,  but  their  nerve  supply. 
Flex  the  arm  to  an  angle  of  150°.  From  a  point  i  1/2 
to  2  inches  above  the  articular  line  make  an  incision 
downwards  along  the  outer  edge  of  the  humerus  to  the 
head  of  the  radius  (Fig.  1156).  Continue  the  incision 
downwards  along  the  outer  margin  of  the  anconeus  to 
the  ridge  of  the  ulna  about  2  inches  below  the  tip  of 
the  olecranon.  The  incision  is  curved  and  should  end 
a  little  to  the  inner  (ulnar)  side  of  the  ulna.  At  the 
upper  end  of  the  incision,  penetrate  to  the  outer  edge 
of  the  humerus  by  separating  the  supinator  longus 
and  the  extensor  capri  radialis  longior  in  front  from 
the  triceps  behind.  From  the  external  condyle  down- 
wards penetrate  between  the  extensor  muscles  (ex- 
tensor carpi  ulnaris,  etc.)  in  front  and  the  anconeus 
behind,  until  the  ulna  is  reached.  In  doing  this  the 
lower  fibres  of  the  anconeus  must  generally  be 
divided.  The  rest  of  the  operation  requires  no  special 
description. 

Ollier's  Bayonet  Incision. — From  a  point  2  1/4 
inches  above  the  joint-line  make  a  vertical  incision 
along  the  outer  margin  of  the  humerus  between  the 

triceps  and  supinator  longus  to  the  tip  of  the  external  condyle.  From  the 
tip  of  the  condyle  continue  the  incision  downwards  and  inwards  to  the  base  of 
the  olecranon,  then  change  the  direction  of  the  incision  once  more  so  as  to  make 
it  follow  the  posterior  border  of  the  ulna  downwards  for  i  1/2  to  2  inches  (Fig. 
1 157).     Make  a  second  incision,  i  inch  long,  over  the  internal  condyle. 

Posterior  Flap  Operation. — Morison  operates  as  follows :  From  a 
point  over  the  internal  condyle  make  an  incision  upwards  for  about  2  inches, 
corresponding  to  the  inner  intermuscular  septum.  Make  a  similar  incision 
on  the  outer  side  of  the  limb  (Fig.  1158).  Join  the  upper  ends  of  the  two  vertical 
cuts  by  a  curved  transverse  incision,  the  upper  convexity  of  which  is  3  inches 
above  the  olecranon.  Expose  the  ulnar  nerve  through  the  inner  incision  and 
protect  it.  Turn  down  the  skin  flap  outlined  for  a  distance  of  i  inch.  Divide 
the  triceps  transversely.  Turn  the  skin  flap  and  triceps  tendon  downwards. 
The  rest  of  the  active  operation  requires  no  special  description.     Close  the 


Fig.   ii:;6. 


990 


ELBOW. 


wound  by  suturing  the  divided  triceps  and  then  the  superficial  wound.  Morison 
permits  no  motion  for  two  weeks,  after  which  time  he  keeps  the  limb  extended 
at  night  and  fully  flexed  during  the  day. 


Fig.  1 157. 


Fig.  1 1 59. — (Lossen.)  Fig.   1160. — (Lossen.) 

Fig.   1159.- — I.  Anconeus.     2.  Ext.    digitorum.     3.  Division  musculo-spiral  nerve.      4. 

Ext.    carpi  radialis   longior.     5.  Supinator  longus.     6.  Musculo-spiral   nerve.     7.  Pronator 

radii    teres.     8.  Brachialis    anticus.     9.  Flexor    muscles    divided.     10.  Ulnar    nerve.     11. 

Tendon  of  triceps. 

Fig.   1160. — -I.  Anconeus.     2.  Extensor     com.    digitorum.     3.   Division  musculo-spiral 

nerve.     4.  Ext.  carpi  radialis  longior.     5.  Supinator  longus.     6.  Musculo-spiral  nerve. 

Bardenheuer's    Operation    (Lossen,    "Deutsche   Zeitschrift   fiir   Chir.," 
xcii,  120)     Extra-capsular  Arthrectomy. 

Step  I. — Reflect  a  horseshoe-shaped  flap  of  skin,  having  its  pedicle  above, 
from  the  posterior  aspect  of  the  joint. 


RESECTION. 


991 


Step  2. — Divide  the  triceps  tendon  above  the  olecranon. 

Step  3. — By  dissection  lay  bare,  but  do  not  penetrate,  the  posterior  and 
lateral  surfaces  of  the  articular  capsule. 

Step  4. — Divide  the  humerus  and  retract  its  articular  end  downwards  (Fig. 
1 1 59),  thus  exposing  the  anterior  surface  of  the  joint. 

Step  5. — Separate  the  overlying  soft  structures  from  the  anterior  surface 
of  the  capsule. 

Step  6. — Divide  the  ulna.  At  a  lower  level  divide  the  radius.  (The 
section  of  the  radius  at  a  lower  level  than  that  of  the  ulna  is  important  for  the 
preservation  of  pronation  and  supination.)  The  articular  ends  of  the  bones 
plus  the  whole  joint  cavity  can  now  be  removed  in  one  piece. 

Step  7. — With  chisel,  forceps,  or  saw  cut  a  V-shaped  notch  in  the  humerus 
(Fig.  1 1 59).  Trim  the  upper  end  of  the  ulna  so  as  to  fit  into  the  notch  in  the 
humerus  while  the  forearm  is  held  in  a  position  of  a 
little  less  than  a  right  angle  to  the  upper  arm.  Unite 
the  ulna  to  the  humerus  by  means  of  a  nail  (Fig.  11 60). 

Step  8. — Close  the  wound. 

Atypical  Resection  of  the  Elbow. — Access  to  the 
joint  is  obtained  through  the  posterior  longitudinal 
incision  already  described.  The  base  of  the  olecranon 
process  is  cleared  of  its  coverings  and  divided  trans- 
versely either  from  without  inwards  with  a  chisel,  or 
from  within  outwards  with  a  Gigli  wire  saw.  The 
olecranon  is  reflected  upwards  with  the  attached  triceps 
tendon.  Examine  the  olecranon  carefully  as  it  is  the 
most  common  site  of  osseous  foci  of  disease  in  tuber- 
culosis of  the  elbow.  With  a  chisel  or  sharp  spoon 
remove  diseased  bone  wherever  found.  With  forceps 
and  knife  or  scissors  excise  diseased  soft  structures. 
Thoroughly  cleanse  the  joint  cavity.  Reunite  the 
olecranon  to  the  ulna  with  bone  pegs,  steel  nails  (the 
ends  protruding  through  the  w^ound),  silver  wire,  or 
chromicized  catgut.  Close  the  wound,  provide  for 
drainage,  and  dress.  Many  surgeons  advise  that  the 
limb  be  kept  in  an  extended  position  for  two  weeks. 

The  after-treatment  is  practically  the   same  as  that  for  other    elbow-joint 
resections. 

Arthrodesis. — Occasionally  after  very  extensive  removal  of  bone  in 
excision  of  the  elbow  a  flail-joint  results.  If  exercises,  etc.,  or  the  use  of  some 
supporting  apparatus  do  not  lead  to  tolerable  results,  it  becomes  necessary  to 
operate.  The  operation  is  practically  that  for  ununited  fracture  and  requires 
no  special  description.  The  endeavor  must  be  to  obtain  bony  union  with 
the  elbow  flexed  to  such  an  angle  that  the  fingers  may  be  brought  up  to  or 
nearly  up  to  the  mouth.     In  cases  of  paralysis  when  the  most  careful  treatment 


Fig.  1 161. 


992  ELBOW. 

has  failed  and  when  no  hope  exists  of  obtaining  a  useful  joint  by  means  of 
tendon  transplantation  or  of  nerve  anastomosis,  it  becomes  necessary  to  operate 
for  the  relief  of  the  resultant  and  useless  flail-joint.  The  joint  must  be  exposed 
as  in  excision;  a  thin  shell  of  bone  must  be  removed  from  the  humerus  and 
the  forearm  bones;  the  sawn  surfaces  must  be  brought  into  good  apposition 
and  kept  there  until  bony  union  has  taken  place.  Of  course  care  must  be 
taken  to  insure  a  useful  position  of  the  elbow. 

Robert  Jones  does  not  consider  the  hip,  wrist,  and  elbow-joints  fitted  for 
bony  fixation.  In  that  uncommon  type  of  paralysis  in  which  the  muscles 
of  the  hand  are  acting,  but  the  shoulder  and  elbow  are  flail,  it  is  necessary  to 
fix  the  arm  in  acute  flexion  so  that  the  functioning  hand  may  be  of  use.  Jones 
does  this  "by  the  excision  of  the  skin  flaps,  fixing  the  forearm  to  the  arm, 
which  is  infinitely  preferable  to  an  arthrodesis  of  the  elbow." 

Jones*  Operation. — Step  i. — At  the  junction  of  the  middle  and  lower 
thirds  of  the  anterior  surface  of  the  upper  arm  choose  the  point  A  (Fig.  i  i6i).  At 
the  junction  of  the  middle  and  upper  thirds  of  the  forearm  choose  the  point  B. 
Between  A  and  B  remove  a  diamond-shaped  area  of  skin  A  B  C  D. 

Step  2. — Attend  to  hemostasis.  With  sutures  unite  the  raw  surface  A  C  D 
to  the  raw  surface  B  C  D  in  such  a  fashion  that  A  is  united  to  B  and  the  cut 
edge  A  C  to  C  B,  etc.  Apply  dressings.  Use  a  sling  for  some  months,  i.  e., 
until  contraction  is  well  advanced. 


CHAPTER  XCVII. 


IRREDUCIBLE  DISLOCATION  OF  THE  ELBOW. 


The  common  causes  which  impede  reposition  of  a  dislocated  elbow-joint 
are:  (i)  Fragments  of  bone  separated  from  the  articular  ends.  (2)  Con- 
traction and  malposition  of  torn  portions  of  capsule  and  ligament.  (3)  Or- 
ganization of  blood-clot.  (4)  The  filling  up  and  obliteration  of  the  olecranon 
and  coronoid  fossae.  When  sutficiendy  good  results  cannot  be  obtained  by 
means  of  non-operative  treatment,  operation  is  generally  justifiable.  The 
operation  of  choice  is  "Operative  Reposition";  if  this  proves  impossible  or 
inadvisable,  it  is  easy  to  proceed  to  excise  and  interpose  a  flap  of  fat  and  fascia 
between  the  divided  bones. 

Operative  Reposition. — Bunge  ("Archiv.  fur  klin.  Chir.,"  Ix,  557) 
gives  an  excellent  account  of  the  operation  as  practised  in  von  Eiselberg's 
clinic.  The  following  is  based  largely  on 
Bunge's  article: 

Apply  an  elastic  constrictor.  On  the  outer 
side  of  the  elbow-joint  make  an  incision  about 
4  inches  in  length  (Fig.  1 162).  This  cut  in  part 
of  its  course  lies  between  the  extensor  carpi 
radialis  longior  and  the  extensor  communis 
digitorum.  Expose  the  dislocated  head  of  the 
radius  and  lateral  pa^-t  of  the  humerus. 
Divide  all  tense  bands  of  scar  tissue  and,  sub- 
periosteally,  lay  bare  the  whole  upper  end  of 
the  radius  and  the  outer  side  of  the  humerus 
at  least  as  far  as  the  origin  of  the  joint  capsule. 
This  is  done  with  scissors  and  periosteal 
elevator.     Through  the  above  incision  inspect 

the  condition  of  the  olecranon  and  coronoid  fossae  and  the  articular  end  of 
the  ulna.  Remove  all  abnormal  masses  of  tissue  until  the  fossae  are  clear  and 
the  normal  configuration  is  displayed.  Carefully  hunt  for  and  remove  any 
displaced  fragments  of  bone.  The  articular  ends  of  the  bone  can  now,  occa- 
sionally, be  luxated  through  the  wound;  the  median  side  of  the  joint  cleared 
of  scar  tissue  and  the  soft  parts  separated  from  the  humerus  and  ulna  in  the 
same  manner  as  already  described. 

Replace  the  bones.  Test  the  mobility  of  the  joint.  If  movement  seems 
to  be  at  all  impeded,  make  a  longitudinal  incision  about  4  inches  in  length 
along  the  inner  side  of  the  joint.     Remember  the  location  of  the  ulnar  nerve 

63  993 


Fig.  1162. 


994 


IRREDUCIBLE    DISLOCATION    OF    THE    ELBOW. 


and  avoid  injuring  it.  The  cut  is  made  a  little  in  front  of  the  internal  epicon- 
dyle.  Through  this  wound  subperiosteally  separate  the  soft  parts  from  the 
bones  until  free  motion  is  obtained.  Remove  the  tourniquet  and  attend  to 
hemostasis  with  the  most  minute  care.  This  is  of  extreme  importance,  as 
the  occurrence  of  a  hematoma  interferes  with  the  after-treatment.  The 
articular  capsule,  the  covering  soft  parts,  and  the  skin  are  each  separately 
sutured  with  catgut.  Dress  and  put  up  in  a  starch  bandage  strengthened  by 
strips  of  pasteboard  or  wire  netting.  The  joint  is  to  be  fixed  at  an  obtuse 
angle  and  fully  pronated. 

After-treatment. — The  sooner  the  after-treatment  is  begun,  the  better 
the  result  will  be.  As  early  as  the  third  or  fifth  day  begin  making  daily  passive 
movements.  As  soon  as  the  wound  has  healed  the  movements  must  be  supple- 
mented by  massage  and  warm  baths  to  the  arm.     At  an  early  date  some  form 


Fig.  1 163. 


Fig.  1164. 


of  pendulum  apparatus  may  be  used  (sand-bag  fixed  to  the  wrist)  as  a  means 
of  exerting  continuous  passive  motion.  Active  movements  should  be  begun 
early.  If  any  signs  of  inflammation  appear,  restrict  or  stop  all  exercises  until 
danger  has  passed.  If  a  hematoma  forms,  it  must  be  emptied  at  once. 
Schlange  considers  that  the  hindrance  to  reduction  is  usually  a  fracture  of  the 
articular  end  of  the  humerus  which  has  not  been  properly  corrected  or  in  which 
there  is  an  excess  of  callus.     He  operates  as  follows: 

1.  Make  an  incision,  on  each  side,  from  the  points  of  the  epicondyles  down- 
wards, inwards  and  backwards  to  the  ulna  about  i  inch  below  the  base  of  the 
olecranon.  Unite  these  converging  incisions  by  a  transverse  cut  across  the 
back  of  the  ulna  (Fig.  1163).  Remember  the  location  of  and  protect  the  ulnar 
nerve.  The  more  or  less  horseshoe-shaped  incision  described  penetrates  to 
the  bone. 

2.  With  a  saw  introduced  through  the  transverse  portion  of  the  incision 
divide  the  ulna  obliquely  upwards  and  forwards  so  as  to  separate  the  olecranon 
process  and  a  wedge-shaped  portion  of  the  shaft  from  the  ulna  (Fig.  11 64). 


EXCISION.  995 

3.  Reflect  upwards  the  flap  of  skin,  triceps  tendon,  and  bone,  and  thus 
freely  expose  the  whole  interior  of  the  joint. 

4.  Remove  any  excessive  callus  and  correct  any  defect  which  interferes 
with  reduction.     Reduce  the  dislocation. 

5.  Replace  the  osteoplastic  flap.  Unite  the  sawn  surfaces  of  the  ulna  by 
means  of  a  nail  which  penetrates  the  skin  and  thus  can  be  subsequendy  re- 
moved. Suture  the  periosteum.  Close  the  wound.  Dress.  Immobilize 
with  the  elbow  extended.  Remove  the  nail  from  the  bone  in  about  ten  days. 
Begin  passive  motion  early  (Schlange,  "Archiv.  fiir  klin.  Chir.,"  Ixxxi,  Part 
II) .  The  head  of  the  radius  may  be  dislocated  forwards,  the  ulna  remaining 
in  situ,  and  the  remains  of  the  orbicular  ligament  may  be  so  placed  between 
the  bones  that  reduction  becomes  impossible,  under  these  circumstances 
operation  may  be  necessary.  Open  the  joint  by  Kocher's  external  incision 
(see  p.  989).  Pick  up  the  torn  ends  of  the  orbicular  ligament.  Reduce  the 
dislocation.  Repair  the  ligaments  by  means  of  sutures.  Close  the  wound. 
Apply  dressings. 


CHAPTER  XCVIII. 
ANCHYLOSIS  ELBOW. 

Anchylosis  of  Elbow. — The  treatment  of  fibrous  anchylosis  consists  in 
breaking  down  the  adhesions,  under  an  anaesthetic, and  in  keeping  them  from 
reforming  by  means  of  proper  passive  and  active  exercises.  Occasionally 
in  very  stubborn  cases  it  may  be  necessary  to  operate  in  the  same  manner  as 
for  osseous  anchylosis.  When  osseous  anchylosis  is  present  treatment  may 
or  may  not  be  necessary.  If  the  elbow  is  fixed  at  such  an  angle  that  the  patient 
gets  fair  use  of  the  limb  and  if  elbow  immobility  does  not,  for  the  individual 
affected,  entail  much  disability,  then  no  treatment  is  demanded.  If,  however, 
owing  to  faulty  position  plus  immobility,  there  is  distinct  disability,  operation 
is  indicated.  Until  recently  the  operative  treatment  was  principally  directed 
against  the  faulty  position  rather  than  against  the  immobility 

This  treatment  consisted  in  ordinary  excision  which  was  made  very  extensive 
if  the  endeavor  was  to  obtain  motion.  Thanks  to  hints  thrown  out  by  Verneuil 
(in  1863),  Oilier,  Helferich,  Rochet,  etc.,  Nelaton  (in  1902)  proposed  a  general 
method  of  treatment  of  bony  anchylosis  by  interposition  of  flaps  of  muscle. 
J.  B.  Murphy  (in  1904)  showed  that  fat  and  fibrous  tissue  was  more  suitable 
than  muscle  for  this  purpose  as  it  is  from  such  tissue  that  the  synovialis  is 
originally  formed.  For  bony  anchylosis  of  the  elbow  it  is  no  longer  essential 
to  make  a  very  extensive  resection,  it  is  only  necessary  to  remove  enough  bone 
to  permit  of  free  motion  after  the  sawn  surfaces  have  been  recovered  with  a 
proper  flap  of  muscle  or  fascia  and  after  the  wounds  in  the  soft  parts  have 
have  been  closed. 

Method  A. — The  author  devised  and  successfully  used  the  following 
method:     Render    the    limb    bloodless.     Apply    an    elastic    constrictor. 

1.  To  the  outer  side  of  the  middle  line  make  a  vertical  incision  from  a  point 
2  inches  above  to  one  3  inches  below  the  tip  of  the  olecranon. 

2.  Reflect  outwards,  by  dissecting  against  the  bone,  all  the  soft  parts  external 
to  the  incision,  laying  bare  the  outer  edge  of  the  lower  end  of  the  humerus  and 
the  outer  side  of  the  olecranon,  but  leaving  the  annular  ligament,  if  possible, 
intact.  Do  the  same  on  the  inner  side  of  the  wound.  Remember  the  ulnar 
nerve. 

3.  With  an  osteotome  separate  the  olecranon  from  the  humerus.  Remove 
most  of  the  olecranon.  Divide  the  bony  tissue  uniting  the  humerus  to  the 
ulna  and  radius.  Completely  divide  the  lateral  ligaments.  Flex  the  elbow 
acutely.     With  the  Gigli  wire  saw,  remove  a  small  portion  of  the  lower  end 

996 


ARTHROPLASTY. 


997 


of  the  humerus.  .  Remove  the  articular  surface  of  the  uhia  and  model  a  new 
sigmoid  cavity.  If  necessary,  remove  part  of  the  head  of  the  radius.  Divide 
any  bony  tissue  uniting  the  radius  to  the  ulna,  if  possible  preserving  part  or 
all  of  the  annular  ligament.  Smooth  and  properly  shape  the  opposing  surfaces 
of  the  radius  and  ulna.  It  is  usually  easy  to  find  enough  soft  structures  (fat, 
fascia,  muscle)  to  interpose  between  the  radius  and  ulna  where  they  normally 
articulate,  without  formally  fashioning  a  t^ap  for  the  purpose.  Trim  the 
edges  of  the  sawn  surface  of  the  humerus. 

4.  Remove  the  elastic  constrictor.  Attend  to  hemostasis.  Pack  the 
deep  wound  with  hot  gauze.     Replace  the  soft  parts  in  position  over  the  gauze. 

5.  On  the  outer  side  of  the  original  wound  reflect  the  skin  from  the  fat  and 
deep  fascia  for  a  great  distance  (Fig.  1165).  Outline  and  dissect  up  a  flap 
having  its  pedicle  above  the  joint-line.  The 
flap  consists  of  fat,  fascia,  and  some  of  the 
superficial  fibres  of  the  subjacent  muscles 
(Fig.  1 165)  (anconeus,  ext.  carpi  ulnaris,  etc.), 
and  must  be  large  enough  to  completely  cover 
the  lower  end  of  the  humerus  and  i  inch  of 
its  anterior  and  posterior  surface. 

6.  Remove  the  pack  from  the  deep  wound. 
Wrap  the  flap  over  the  lower  end  of  the 
humerus,  fixing  it  with  a  few  stitches  of  fine 
catgut. 

7.  Flex  the  arm  to  about  a  right  angle. 
Replace  the  tissues  as  well  as  possible  into 
their  normal  positions.  Most  of  the  triceps 
tendon  is  intact  (on  the  inner  side  of  the  orig- 
inal wound)  and  continuous  with  the  perios- 
teum of  the  ulna.  Close  the  deep  wound 
with  catgut  sutures.  Provide  drainage  (rub- 
ber tissue).  Close  the  skin  wound.  Dress. 
Apply  a  right-angled  anterior  splint.  After-treatment: 
about  twenty-four  hours.     Begin  motion  in  about  eight  days. 

Method  B. — Expose  the  joint  as  in  Method  A. 

2.  Rupture  of  the  anchylosis.* — First  try  to  rupture  the  anchylosis  by 
manual  force.  If  this  fails,  introduce  a  rugine  between  the  olecranon  and 
the  humerus  as  a  lever  or,  better,  divide  the  olecranon  near  its  base,  and  after 
having  cut  the  fibrous  bands  uniting  the  humerus  to  the  forearm  bones,  once 
more  try  to  break  the  anchylosis  by  manual  force. 

If,  as  is  rare,  the  above  means  fail,  one  must  separate  the  bones  with  chisel 
and  mallet. 

3.  Divide  the  humerus  at  a  point  where  its  diameter  begins  to  diminish 

*  The  description  of  this  and  the  following  method  is  based  on  Huguier's  Traitement  des 
.\nkyloses. 


Fig.   ii6s. 


Remove  the  drain  in 


998 


ANCHYLOSIS   ELBOW. 


(Fig.   1 1 66).     Fashion  the  sawn  surface  so  that  it  is  convex  from  before  back- 
wards. 

4.  Resect  the  olecranon  at  its  base.  Fashion  the  bone  as  shown  in  Figures 
1 167  and  1 168.  Resect  that  portion  of  the  head  of  the  radius  which  projects 
above  the  sawn  surface  of  the  ulna.  If  anchylosis  exists  between  the  radius 
and  ulna  separate  these  bones  with  a  fine  chisel. 

5.  Remove  the  elastic  constrictor.  Attend  to  hemostasis  with  unusual 
care. 

6. — Interposition  of  Muscle. —  (a)  Flex  the  forearm  acutely.  Divide 
the  anterior  articular  capsule  transversely  at  its  ulnar  insertion;  continue  this 
incision  into  the  branchialis  anticus,  so  as  to  form  the  muscular  flap  (Fig.  11 68) 
(Quenu).  With  the  flap  cover  the  sawn  surface  of  the  humerus.  The  rest 
of  the  operation  is  as  in  Method  A. 


Fig.   1 166. — {Huguier.) 


Fig.   1167. — (Huguier.) 


(b)  Berger  obtains  the  muscular  flap  from  the  anconeus.  Figure  1169 
sufficiently  explains  the  operation. 

Method  C. — Lateral  Incisions  (Ombredanne). — Make  a  5-inch  vertical 
incision  on  the  inner  side  of  the  elbow.  Isolate  and  protect  the  ulnar  nerve. 
Denude  the  epitrochlea.  Divide  the  lateral  ligament.  Denude  the  anterior 
surface  of  the  humerus.  On  the  outer  side  of  the  elbow  make  a  vertical  in- 
cision downwards  from  a  point  21/2  inches  above  the  joint-line.  If  it  is  neces- 
sary to  carry  this  cut  more  than  i  1/2  inches  below  the  joint-line  it  ought  to  in- 
cline backwards  so  as  to  avoid  injury  to  the  radial  nerve.  Denude  the  epi- 
condyle  with  a  knife,  the  anterior  surface  of  the  condyle  with  a  rugine.  Divide 
the  external  lateral  ligament.  Rupture  the  anchylosis  as  already  described. 
Make  the  lower  end  of  the  humerus  protrude  through  the  internal  wound  and 
divide  it  transversely  immediately  below  its  lateral  tuberosities.  Figure  11 70, 
in  conjunction  with  what  has  already  been  written,  sufficiently  describes  the 
remainder  of  the  operation. 


JOINT    TRANSPLANTATION. 


999 


Transplantation  of  Cartilage  in  the  Treatment  of  Anchylosis. — 
Weglowski's  operation  ("Zentralblatt  fur  Chir.,"  1907,  No.  17).  This  opera- 
tion has  been  performed  successfully  by  Weglowski  and  by  Diakonow  in  bony 
anchylosis  of  the  elbow. 

Step  I. — Expose  the  elbow.  Remove  all  excess  of  bone.  Model  the  ends 
of  the  bone  so  as  to  form  proper  articular  surfaces. 

Step  2. — Expose  the  cartilage  of  the  sixth  and  seventh  ribs  and  from  them 
remove  t^vo  plates  of  cartilage  with  perichondrium  the  full  length  and  width 
of  the  costal  cartilage  and  about  one-half  its  thickness. 

Step  3. — Place  these  strips  of  cartilage  between  the  new-formed  articular 
surfaces  of  the  elbow.     The  strip  laid  against  the  articular  surface  of  the 


Fig.  1 168. — (Huguier.) 
b,  Brachialis  anticus;  h,  humerus;  c,  ulna;  i,  triceps;  /,  anterior  ligament  turned  in  with  flap. 

humerus  must  have  its  perichondrial  surface  directed  towards  that  bone.  It 
is  unnecessary  to  fix  the  cartilage  in  position  with  sutures. 

Step  4. — Close  the  wound.  Immobilize.  After  ten  days  begin  active  and 
passive  motion.  In  both  cases  the  result  was  good.  One  patient  died  of  pleuro- 
pneumonia five  weeks  after  operation,  thus  giving  opportunity  for  anatomical 
examination  which  showed  that  the  transplanted  cartilage  lived  and  was  adapt- 
ing itself  satisfactorily  to  its  new  surroundings  and  functions. 

Bony  Anchylosis  Elbow. — Buchmann's  Operation. — Transplantation 
of  an  Entire  Joint. — P.  Buchmann  has  operated  as  follows  in  two  cases  of 
bony  anchylosis  of  the  elbow  ("Zentralblatt  fiir  Chir.,"  1908,  No.  19). 

Step  I. — Make  a  posterior  longitudinal  incision  down  to  the  triceps  tendon 
and  the  olecranon.  At  the  outer  side  of  the  olecranon  divide  all  soft  parts 
longitudinally.  With  an  elevator  separate  and  push  inwards  the  triceps  tendon, 
remnants  of  capsule,  and  the  periosteum. 

Stei)  2. — Divide  the  olecranon  at  the  level  of  the  joint.     Divide  the  lateral 


ANCHYLOSIS   ELBOW. 


Fig.   1 169. — {Huguier.)  FiG.  11 70. — {Huguier.) 

Fig.  1169. — a,  Anconeus  interposed;  r,  radius;  c,  ulna;  Ic,  flap  of  ext.  ulnaris;  cp,  inter- 
posed; t,  triceps;  t',  tendon  triceps;  ca,  Flexor  ulnaris;  cs,  supinator  brevis;  ap,   aponeurosis. 

Fig.  1170. — h,  Humerus;  c,  ulna;  le,  external  muscle  flap;  //,  internal  muscle  flap;  r, 
radius;  re,  extensor  carpi  radialis  longior. 


Fig.   1 17 1. — {Bvichmann.) 


Fig.   1 1 72. —  (Buchmami.) 


JOINT    TRANSPLANTATION. 


lOOI 


remnants  of  capsule.  Divide  the  bony  union  between  the  humerus,  uhia  and 
radius. 

Step  3. — Flex  the  elbow.  From  the  trochlea  cut  out  a  niche,  wider  in  front 
than  behind  and  narrower  above  than  below.  Remove  a  very  thin  slice  from 
the  lower  end  of  the  humerus. 

Step  4. — Separate  the  brachialis  anticus  from  its  insertion  into  the  coronoid 
process.  Cut  a  quadrangular  niche  in  the  ulnar  epiphysis  (Figs.  1171,  1172). 
Remove  the  head  of  the  radius  and  separate  the  radius  from  the  ulna. 


Fig.   1 173. — (Buchmann.) 


Step  5. — Excise  the  first  metatarso-phalangeal  articulation  without  opening 
the  joint  itself.  Remove  with  the  joint  sufficient  metatarsus  and  phalanx  to 
fit  into  the  niches  cut  in  the  humerus  and  ulna. 

Step  6. — Implant  the  excised  joint  into  the  wound  at  the  elbow  in  such  a 
manner  that  its  plantar  surface  faces  backwards.  Fit  the  end  of  the  meta- 
tarsus and  the  phalanx  into  the  corresponding  niches  cut  in  the  humerus  and 
ulna. 

Step  7. — Close  the  elbow  wound  and  immobilize  in  the  extended  position 
Close  the  wound  in  the  foot. 

Figure  1173  shows  a  skiagram  of  one  of  Buchmann's  cases  ten  and  one- 
half  weeks  after  the  operation. 


CHAPTER  XClX. 
WRIST. 

Anatomically,  the  wrist-joint  is  formed  between  the  radius  and  the  triangular 
iibro-cartilage  above  and  the  first  row  of  carpal  bones  below.  Below  the  ana- 
tomical wrist-joint  there  are  the  carpal  and  the  carpo-metacarpal  joints.  These 
joints  are  surronded  by  many  ligaments.  Surgically,  the  series  of  joints  and 
bones  between  the  radius  and  the  metacarpal  bones  may  be  considered  as  one 
structure,  completely  surrounded  by  one  periosteo-ligamentous  investment,  an 
investment  which  is  here  thicker,  there  thinner;  here  more  firmly,  there  less 
firmly  united  to  its  contents.  Numerous  tendons  pass  over  or  are  inserted  into 
this  ligamentous  investment  so  that  if  the  latter  is  separated  from  its  contained 
bones  the  tendons  also  are  separated  or  raised  from  them  without  being  injured. 

Typical  Subperiosteal  Resection  of  the  Wrist. — Ollier's  Operation. 

Step  I. — Incision  Through  the  Skin  and  Ligamentous  Investment. — 
Note  the  position  of  the  styloid  processes  of  radius  and  ulna  and  imagine  a  line 
joining  these  two  joints  (interstyloid  line).  Note  the  tendon  of  the  extensor 
indicis  or  if  this  cannot  be  made  out,  the  base  of  the  second  metacarpal  bone. 

Beginning  at  the  middle  of  the  dorsal  aspect  of  the  second  metacarpal  bone, 
make  an  incision  upwards  and  inwards  a  little  to  the  radial  side  and  follow- 
ing the  line  of  the  tendon  of  the  extensor  indicis  (Fig.  1174).  This  oblique 
incision  reaches  the  middle  point  of  the  interstyloid  line  where  its  direction  is 
changed  to  that  of  the  axis  of  the  forearm. 

Recognize  and  retract  inwards  the  tendon  of  the  extensor  indicis,  without 
opening  its  sheath.  This  exposes  the  insertion  of  the  extensor  carpi  radialis 
brevior.  Incise  the  periosteum  of  the  head  of  the  third  metacarpal  to  the  inner 
side  of  the  insertion  of  the  extensor  carpi  radialis  brevior.  Continue  the  peri- 
osteal incision  upwards,  dividing  the  joint  capsule  and  the  posterior  annular 
ligament  between  the  extensor  indicis  and  the  long  extensor  of  the  thumb. 

On  the  ulnar  side  of  the  wrist  make  an  incision  from  a  point  i  1/4  inches 
above  the  point  of  the  ulnar  styloid  process  to  a  point  3/4  inch  above  the  base 
of  the  fifth  metacarpal  bone.  The  incision  is  to  the  inner  side  of  the  extensor 
carpi  ulnaris,  and  is  carried  directly  to  the  bone. 

Step  2. — Removal  of  the  Carpal  Bones. — Through  either  the  dorsal  or 
ulnar  incision  separate  the  ligamentous  investment  from  the  underlying  struc- 
tures, seize  the  individual  bones  in  forceps  and  dissect  them  out.  If  the  liga- 
mentous investment  is  properly  separated,  the  tendinous  insertions  will  be 
preserved  and  the  least  possible  amount  of  damage  inflicted.  The  pisiform 
bone  may  or  may  not  be  removed.  The  unciform  process  may  be  divided 
while  its  bone  is  being  removed  and  if  not  diseased  it  may  be  left  in  situ. 

1002 


EXCISION. 


lOO' 


Step  3. — After  the  removal  of  the  carpal  bones  it  is  easy  to  resect  the  lower 
end  of  the  radius  and  ulna  and  to  remove  the  triangular  cartilage.  The  carpal 
ends  of  the  metacarpal  bones  are  readily  excised  with  rongeur  forceps. 

Step  4. — Review  the  whole  wound  and  excise  with  forceps  and  scissors  any 
diseased  tissue.  Unite  by  suture  the  divided  annular  ligament.  In  cases  of 
tuberculosis  rub  the  wound  cavity  with  iodoform.  Provide  tubular  drainage. 
Close  the  wounds  with  sutures.  Some  surgeons  pack  the  wound  with  iodoform 
gauze  and  suture  after  the  lapse  of  a  few  days,  or  they  apply,  but  do  not  tie,  the 


Fig.   1174. — (After  Far abeuf.) 
R,  Radius;  C,  ulna;  Sc,  scaphoid;  /,  trapezoid;  i-i',  tendon  ext.  carpi  radialis  long.; 
2-2',  ext.  carpi  radialis  brevior;  ^-^',  ext.  ossis  metacarpi  pollicis;  4-4',  ext.  brevis  poUicis; 
5-5',  ext.  longus  pollicis;  6-8-9-10,  ext.  communis;  7-7',  ext.  indicis;  ii-ii',  ext.  minim,  dig.; 
12-12',  ext.  carpi  ulnaris. 

sutures  on  the  completion  of  the  operation,  pack  with  gauze,  remove  the  pack 
after  a  few  days,  and  tie  the  sutures  already  in  place.  Instead  of  the  above 
dressings  the  wound  may  be  filled  with  iodoform  or  bismuth  paste  and  closed 
with  or  without  drainage.  After  the  dressings  have  been  applied  the  member 
must  be  fixed  with  the  hand  in  a  position  of  dorsal  flexion.  Various  special 
splints  have  been  devised  for  this  purpose.  The  author  uses  a  plain  anterior 
splint  of  wood,  reaching  from  near  the  elbow  to  the  roots  of  the  fingers.  The 
necessary  dorsal  flexion  is  obtained  by  means  of  padding,  and  the  whole  is 


I004 


WRIST. 


kept  in  place  by  starch  bandages.  Possibly  a  better  means  of  lixation  is  plaster 
of  Paris,  strengthened  by  a  wide  strip  of  tin  imbedded  in  the  plaster  on  the  ante- 
rior surface  of  the  arm,  and  bent  to  give  the  requisite  amount  of  flexion.  What- 
ever means  of  immobilization  is  adopted,  the  fingers  and  thumb  must  be  left 
uncovered  so  that  they  may  be  exercised  as  early  as  possible. 

After-treatment. — At  the  earliest  date  possible,  practise  passive  motion  of 
the  fingers  and  thumb.  The  patient  should  be  encouraged  to  do  this  himself. 
Active  movements  of  the  fingers  and  thumb  must  be  early  attempted  and  the 
patient  told  to  make  "piano-playing"  movements.  All  these  movements  are 
of  extreme  importance  so  that  fibrous  union  of  the  tendons  may  be  avoided. 
The  limb  must  be  kept  immobilized  until  the  wrist  has  solidified  considerably. 
This  may  take  six  months  or  even  longer.  When  the  wound  is  healed  a  light 
splint,  e.  g.,  Ollier's  wire  splint  or  some  leather  device,  should  replace  the 
original  plaster  or  starch  bandages.     The  extensor  and  tlexor  muscles  of  the 


Fig.   1 1 75. — (Taylor.) 

wrist  should  be  kept  in  "condition"  by  applications  of  electricity.  The  splint 
should  be  removed  several  times  daily  and  passive  movements  of  the  wrist 
practised.     Much  patience  is  required  before  a  good  result  can  be  obtained. 

The  operation  is  usually  performed  for  tuberculous  disease.  Miiller  has 
excised  the  wrist  in  arthritis  deformans  with  good  results.  In  one  case  of  arth- 
ritis deformans  the  author  obtained  a  result  which  was  only  fair,  but  this  he 
thinks  partially  due  to  want  of  completeness  in  the  operation  done. 

Wm.  J.  Taylor's  Operation  ("Annals  of  Surgery,"  xxxii,  360). — This  is 
a  modification  of  an  operation  suggested  by  Studsgaat  and  carried  out  by 
Mynter. 

Apply  an  elastic  constrictor  above  the  elbow. 

Step  I. — Make  a  longitudinal  dorsal  incision  from  the  lower  end  of  the  radius 
downwards  along  tJie  line  corresponding  to  the  space  between  the  second  and 
third  metacarpal  bones  (Fig.  11 75).  Through  this  incision  penetrate  between 
the  metacarpal  bones  to  their  palmar  surface,  but  be  careful  not  to  injure  the 
soft  tissues  of  the  palm.  (Mynter  made  a  small  palmar  as  well  as  a  long  dorsal 
incision.)  Split  the  carpal  bones.  This  splitting  is  easy,  as,  when  operation  is 
required  because  of  tuberculosis,  the  bones  afifected  are  softened  or  destroyed 
by  the  disease. 


RESECTION. 


1005 


Step  2. — Remove  all  diseased  tissue.  Clean  thoroughly.  Lessen  the  size 
of  the  deep  wound  by  means  of  a  few  sutures.  Loosely  pack  with  gauze. 
Partially  close  the  skin  wound.     Dress.     Apply  a  suitable  splint. 

Bardenheuer's  Operation. — Through  a  suitable  incision  remove  the 
carpus  en  masse.  If  possible  preserve  the  trapezius  so  as  to  retain  the  mobility 
of  the  thumb.  Obliterate  the  head  space  left  by  the  removal  of  the  carpus  in 
the  following  manner:  Divide  the  three  middle  metacarpal  bones  so  as  to  form 
a  wedge  whose  apex  is  formed  by  the  third  metacarpal.  Fashion  the  forearm 
bones  so  as  to  form  a  V-shaped  surface  and  into  this  V  place  the  metacarpal 
wedge.  Nail  the  third  metacarpal  to  the  radius;  the  tifth  metacarpal  to  the 
ulna,  and  the  trapezius  to  the  outside  of  the  radius.  Any  tendons  which  have 
been  resected  because  of  involvement  in  the  disease  are  now  reunited  by  suture. 

Atypical  Resection  of  the  Wrist. — In  tuberculosis,  limited  foci  of  disease 
may  be  safely  reached  through  small  incisions  on  any  part  of  the  dorsum  of  the 
wrist,  if  care  is  taken  to  avoid  division  of  tendons.  In  more  advanced  carpal 
disease  access  may  be  obtained  through  Ollier's  incisions  and  the  affected 
structures  removed  with  the  sharp  spoon,  forceps,  and  scissors.  After  such 
operations  the  wounds  are  carefully  cleaned,  iodoformized  and  either  packed 
with  iodoform  gauze  or  closed  by  suture  after  drainage  is  provided. 


CHAPTER  C. 

WRIST   ANCHYLOSIS. 

Method  A. — Nelaton's  Operation,  ("Rev.  d'orthopedie,"  1905.  Nekton; 
''Traitement  des  Ankyloses,"  Huguier). 

1.  Expose  the  wrist-joint  by  a  longitudinal  incision  along  the  radial  side 
of  the  extensor  tendons  of  the  index  finger.  Extend  the  incison  upwards  so  as 
to  freely  expose  the  lower  portion  of  the  extensor  communis  digitorum.  Re- 
tract the  extensors  of  the  thumb  outwards,  those  of  the  fingers  inwards. 

2.  Break  down  the  anchylosis  by  manipulation  or  with  the  chisel.  Excise 
the  first  row  of  carpal  bones,  except  the  pisiform.  Resect  sufficient  of  the  second 
row  of  bones  in  a  curve,  to  give  them  the  shape  of  a  condyle. 


exc... 


Fig.  1 1 76. — (Huguier.) 
r,  Radius;  c,  ulna;  m,  metacarpus;  exc,  ext.  communis  digitorum;  /,  tendon  ext.  indicis; /e^, 

ext.  long,  pollicis. 

3.  From  the  outer  side  of  the  fleshy  body  of  the  extensor  communis  digitorum 
cut  a  flap  having  its  pedicle  below.  The  flap  must  be  about  1/2  inch  wide 
by  2  inches  long.  Place  the  flap  transversely  in  the  gutter  formed  by  the  re- 
moval of  the  carpus  and  fix  its  end  to  the  fibrous  tissue  at  the  inner  side  of  the 
joint  (Fig.  1 176). 

4.  Stop  all  bleeding.  Close  the  wound  after  providing  for  drainage. 
After  two  weeks  begin  motion.  Nelaton  operated  successfully  in  this  fashion 
in  a  case  of  anchylosis  from  arthritis. 

1006 


ARTHROPLASTY. 


1007 


Method  B. — The  author  suggests  the  following  method  as  simpler  and  at 
least  as  efScacious  as  Nekton's;  it  is  almost  identical  with  an  operation  for 
anchylosis  of  the  first  carpo-metacarpal  joint  which  he  performed  successfully. 

1.  Expose  the  wrist-joint  by  a  longitudinal  incision  along  the  radial  side  of 
the  extensor  of  the  index  finger.  Divide  the  skin,  fascia,  etc.,  so  as  to  open  the 
joint.  Do  not  cut  the  fascia  upwards  any  further  than  is  absolutely  necessary. 
Break  down  the  anchylosis  and  excise  bone  from  the  carpus  to  the  extent 
necessary  for  free  motion,  as  in  Nelaton's  operation. 

2.  Extend  the  original  incision  upwards  dividing  the  skin  alone  (Fig.  1177). 
Expose  a  large  surface  of  the  fascia  of  the  forearm.     From  the  fascia  dissect 


Fig.  I 177. 
E,  Deep  fascia;  F,  flap  of  fascia;  D,  carpal  bones. 


downwards,  a  flap  of  fascia,  fat,  and  a  few  muscle  fibres  (pedicle  below  and 
sufficiently  above  or  to  the  side  of  the  opening  made  in  the  fascia  for  the 
arthrectomy  to  permit  of  good  nutrition). 

3.  Turn  the  flap  of  fascia  downwards,  tuck  it  into  the  deep  wound  so  that  it 
completely  envelopes  the  articular  surface  of  the  radius.  Fix  the  flap  in  position 
with  fine  catgut  sutures. 

4.  Close  the  wound  after  providing  for  drainage.  Apply  dressings  and  a 
splint.  Remove  the  drain  in  twenty-four  or  forty-eight  hours.  Begin  motion 
as  soon  as  the  wound  is  healed. 


CHAPTER    CI. 
METACARPO-PHALANGEAL  DISLOCATIONS. 

Dorsal  dislocations  of  the  first  metacarpo-phalangeal  joint  are  occasionally 
irreducible  by  manipulation  and  demand  operation.  Stimson  (Fractures  and 
Dislocations,  p.  707)  writes:  "The  cause  of  this  difficulty,  in  all  the  cases  in 
which  I  have  exposed  the  joint,  has  been  the  torn  edge  of  the  anterior  ligament 
closely  drawn  across  the  back  of  the  metacarpal  behind  its  head,  and  a  slight 
nicking  of  that  edge  made  reduction  easy." 

The  Operation. — Make  a  longitudinal  incision  over  the  palmar  surface  of 
the  prominent  head  of  the  metacarpus.  As  soon  as  the  head  is  exposed,  retract 
the  edges  of  the  wound  and  note  that  the  anterior  ligament  (capsule)  has  been 
torn  from  its  metacarpal  insertion  and  its  edge  can  be  seen  above  it  and  close  to 


Fig.  1 178. 


Fig.  1 180. 


U 


the  phalanx.  Longitudinally  divide  or  nick  the  capsule,  and  reduction  becomes 
easy. 

Frequently  the  capsule  curls  tightly  over  the  articular  surface  of  the  phalanx 
in  this  condition.  The  nicking  of  the  capsule  makes  it  easy  to  pull  the  ofifending 
membrane  out  of  its  false  position  by  means  of  hooks.  Close  the  wound  in  the 
capsule  with  fine  catgut.  Close  the  skin  wound.  Dress.  Begin  movements 
in  about  one  week. 

In  cases  of  old  unreduced  dislocations  of  one  or  other  of  the  metacarpo- 
phalangeal joints,  Friedrich  recommends  resection  of  the  head  of  the  metacar- 
pus, but  gives  warning  that  pain  on  motion  may  persist  for  a  long  time. 


1008 


CHAPTER  CII. 

SYNDACTYLISM.     WEBBED  FIN3ERS. 

The  easiest  way  in  which  to  operate  for  webbed  lingers  in  merely  to  divide 
the  web  and  suture  the  resulting  wounds.  Unfortunately  there  always  results 
a  contraction  of  the  wound  near  the  root  of  the  fingers  and  the  condition  recurs 
to  a  large  extent.  The  following  are  the  principal  operations  devised  to 
prevent  recurrence: 

I.  Perforate  the  web  at  its  apex.  Through  the  perforation  pass  a  stout 
silver  wire.  Keep  the  wire  in  situ  until  the  perforation  is  thoroughly  healed 
when  the  rest  of  the  web  may  be  divided  and  the  wounds  sutured. 

II.  On  the  dorsal  surface  of  the  web  make  the  triangular  incision  ABC, 
(Fig.  1 178)  and  reflect  the  flap  A  C  D,  which  should  be  thick  and  well  nourished. 
Divide  the  web  uniting  the  fingers.  Turn  the  flap  A  C  D  between  the  divided 
fingers  and  suture  the  apex  D  of  the  flap  to  the  palmar  side.  Either  suture 
the  wounds  caused  by  the  division  of  the  web  or  bring  them  together  with  ad- 


hesive strips  and  dress  with  an  ointment  containing  Scharlach  red.  Schreiber 
"(Zentralblatt  fUr  Chir.,  igio.  No.  29)"  claims  much  for  this  operation. 

III.  Didot's  operation. 

Step  I. — On  the  dorsum  of  the  fingers  and  web  make  the  incisions  BACD, 
Fig.  1 179  and  reflect  the  flap  outlined. 

Step  1 179. — On  the  palmar  aspect  make  the  incision  F  E  H  G,  Fig.  1180, 
and  reflect  the  flap  outhned. 

Step  3. — Divide  the  rest  of  the  web. 

Step  4. — Make  the  flap  BACD  envelop  the  finger  to  which  it  is  attached 
(Fig.  1 181)  and  suture  it  in  place.  Similarly  envelop  the  other  finger  with  the 
flap  F  E  H  G.  Figs.  1181  and  1182  are  self-explanatory. 


64  1009 


CHAPTER  cm. 

TRIGGER ;  SNAPPING  OR  SPRING  FINGER. 

Occasionally  after  a  finger  is  flexed  until  its  tip  touches  the  palm  it  can  only 
be  extended  by  a  considerable  muscular  effort  or  by  the  aid  of  the  other  hand. 
**  In  overcoming  the  hitch  by  the  action  of  the  extensor  muscles  the  finger  springs 
back  suddenly  and  usually  with  more  or  less  pain."  The  cause  of  the  trouble 
is  either  an  enlargement  or  nodulation  of  the  tendon  or  a  narrowing  of  the  tendon 


Fig.   1 183. — (Weir.) 
Needle  in  tendon.     Payer's  case. 


Fig.  1184. — (Weir.) 
Split  tendon.     Haegler's  case. 


sheath.  When  trauma  is  the  exciting  cause,  the  lesion  is  usually  found  in 
the  fingers,  in  other  cases  the  obstruction  is  almost  always  in  the  short  space  be- 
tween the  digito-palmar  fold  and  the  first  fold  or  wrinkle  of  the  palm.  If 
the  trouble  does  not  soon  disappear  under  bloodless  treatment  and  if  it  is  very 

lOIO 


TRIGGER    FINGER. 


lOII 


annoying  or  disabling,  operation  is  indicated.  The  principle  of  operation  is 
free  exposure;  removal  or  repair  of  any  very  evident  lesion  (Figs.  1183,  1184, 
1 185,  1 1 86),  and  closure  of  the  wound. 


Fig.   1 185. — (Weir.) 
Tumor  causing  trigger  finger. 


Fig.  11S6.— (Weir.) 
Enlargement  deep  flexor. 


Fig.    1187. — {Weir  from  Spalteholz.) 

When,  as  is  commonly  the  case,  there  is  a  fusiform  swelling  of  the  tendon  or 
merely  a  thickened  sheath,  Weir  recommends  that  the  sheath  be  split  (Fig.  1187) 
and  left  open,  the  superficial  wound  being  closed  (Weir,  "Journ,  A.  M.  A," 
Oct.  5,  1907). 


CHAPTER  CIV. 

OPERATIONS  FOR  INFECTIVE  LESIONS  OF  THE  HAND. 

From  the  standpoint  of  practical  surgery  the  vast  majority  of  standard 
works  on  Anatomy  are  wofully  unsatisfactory  in  their  description  of  the  anatomy 
of  the  hand.  Poirier  and  Charpy,  in  their  colossal  "Traite  d'Anatomie  Hu- 
maine"  give  much  information  regarding  the  tendon  sheaths  of  the  palm, 
while  Allen  B.  Kanavel  deserves  much  thanks  for  an  encyclopedic  article  or 


Superficial  palmar  arch  -- 
Beep  pal  mar  arch  ■- 

Siiperjicialis  volw 
Radial  artery 


Ivfea-iorfold 

-•  Middle  fold 

Superior  fold 


—  Ulnar  artery 


Fig.  ii88.— (Mo/-r/i-.) 
Relation  of  the  palmar  arches  to  the  folds  of  the  palm. 

series  of  articles  on  the  hand  and  its  infections  ("Surg.  Gyn.  Obstetrics," 
Sept.,  1905;  Nov.,  1907;  Jan.,  and  Feb.,  1909).  These  publications  are  freely 
used  in  the  preparation  of  this  chapter.  In  order  to  operate,  with  any  degree 
of  precision,  for  the  relief  of  infective  lesions  of  the  hand  a  fair  knowledge  of 
anatomy  is  requisite. 

Figure  1188  shows  the  position  of  the  palmar  arches. 

Figures  1189,  1190,  and  1191  show  the  usual  arrangements  of  the  synovial 
sheaths  of  the  flexor  tendons  of  the  hand  and  how  the  sheaths  in  the  fingers  do 
or  do  not  communicate  direcdy  with  the  palmar  sheaths  or  bursae.  The  synov- 
ial sac  surrounding  the  more  internal  of  the  common  flexors  lies  on  the  ulnar 
side  of  the  palm  and  wrist  (Fig.  1192).  As  this  sac  forms  a  pouch  in  front  of 
the  superficial  flexors,  separates  the  superficial  from  the  deep  flexors  and  forms 
a  pouch  behind  the  deep  flexors,  it  may  be  considered  as  consisting  of  three 

1012 


ANATOMICAL. 


IOI3 


pouches  (pre-,  inter-,  and  retro-tendinous),  all  opening  into  a  common  pouch — 
the  ulnar  or  cubital  bursa.  The  importance  is  evident  of  recognizing  this 
complicated  arrangement  when  it  is  necessary  to  drain  pus  from  the  ulnar 
bursa.     The  other  palmar  bursas  are  not  so  complicated. 

The  synovial  sheaths  of  the  extensor  tendons  about  the  wrist  are  compara- 
tively simple  (Fig.  1193).  Besides  the  synovial  sheaths  and  bursae  there  are 
certain  well-defined,  uniform  spaces  upon  the  fingers,  palm,  and  dorsum  of  the 
hand  in  which  pus  can  accumulate.  A  section  (Fig.  1 194)  made  through  the  hand 
I  3/S  inches  (3.5  cm.)  proximal  to  the  metacarpo-phlangeal  joints  shows  a 
number  of  these  spaces  admirably,  while  a  section  (Fig.  1195)  taken  a  little 
higher  up  through  the  distal  part  of  the  thenar  area  shows  another  view  of 


Fig.  1 189. 
{Poirier  and  Charpy.) 


Fig.  1 1 90. 

{Poirier  and  Charpy.) 


Fig.  1191. 
{Poirier  and  Charpy.) 


these  same  spaces.  Kanavel,  in  a  recapitulation  of  some  of  his  findings,  writes: 
"We  note  that  we  have  five  great  spaces,  with  their  tributaries,  in  which  pus  can 
accumulate. 

^^ First,  the  dorsal  subcutaneous,  which  is  an  extensive  area  of  loose  tissue, 
without  definite  boundaries,  allowing  pus  to  spread  over  the  entire  dorsum  of 
the  hand. 

'^Second,  the  dorsal  subaponeurotic,  limited  upon  its  subcutaneous  side  by 
the  dense  tendinous  aponeurosis  of  the  extensor  tendons,  upon  the  deep  side 
by  the  metacarpal  bones,  having  the  shape  of  a  truncated  cone,  with  the  smaller 
end  at  the  wrist  and  the  broader  at  the  knuckle.  Laterally  the  aponeurotic 
sheet  shades  off  into  the  subcutaneous  tissue. 

"  Third,  the  hypothenar  area,  a  distinctly  localized  space. 

"FotirtJi,  the  thenar  space,  occupying,  approximately,  the  area  of  the  thenar 
eminence,  to  the  flexion  adduction  crease  of  the  thumb,  not  going  to  the  ulnar 
side  of  the  middle  metacarpal.  It  should  be  remembered  that  this  space  lies 
deep  in  the  palm,  just  above  the  add  ctor  transversus. 

^^ Fifth,  the  middle  palmar  space,  with  its  three  diverticula  below  along  the 
lumbrical  muscles,  limited  by  the  middle  metacarpal  bone  upon  the  radial  side 


IOI4 


OPERATIONS    FOR   INFECTIVE    LESIONS    OF    THE   HAND. 


overlapped  by  the  ulnar  bursa  upon  the  ulnar  side,  and  separated  from  the  the- 
nar space  by  a  partition  which  is  very  tirm  everywhere  except  at  the  proximal 
end,  where  it  is  rather  thin.     A  small  isthmus  can  be  found  leading  from  the 


Intertendinous 
pouch 


Retrotendinous 
pouch 


Fig.   II02. — (Poirier  and  Char py.) 


Fig.   1193. — (Poirier  and  Charpy.) 


proximal  end  of  the  space  under  the  tendons  and  ulnar  bursa  at  the  wrist  up  into 
the  forearm." 

Figures  1196,  1197,  and  1198  show  the  best  sites  for  incisions  in  infections 
of  the  hand  and  the  best  route  for  securing  drainage  of  the  midpalmar  and 


WOUNDS. 


loiq 


thenar  spaces.  In  any  case  of  extensive  or  deep  suppuration  of  the  hand 
when  operation  has  been  decided  on,  it  is  well  if  possible  to  administer  a  gen- 
eral anaesthetic,  apply  an  elastic  constrictor  to  the  upper  arm  and  operate 
deliberately  with  a  precision  rendered  possible  by  a  knowledge  of  anatomy 
and  an  absence  of  blood. 

After  providing  for  drainage,  apply  liberal  dressings  and  use  Bier's  hyper- 
aemia  by  means  of  an  elastic  constrictor.     As  an  alternative  one  may  evacuate 


D5C5       V     l^1 


Fig.  1 194. — (Kanavel.) 
Cross  section,  3  1/2  cm.  proximal  to  joint,  ss,  Synovial  sheath;  Dscs,  dorsal  subcuta- 
neous space;  dsas,  dorsal  subaponeurotic  space;  etc,  extensor  communis  tendon;  ft,  flexor  ten- 
don; LM,  limbrical  muscle;  IM,  interossei  muscle;  M,  metacarpal  bone;  BV,  blood  vessels;  N, 
nerves;  TS,  thenar  space;  MPS,  middle  palmar  space;  atp,  adductor  transversus  poliicis;  dim, 
dorsal  interosseous  membrane;  pim,  palmar  interosseous  membrane;  UB,  ulnar  bursa;  is, 
spice  between  adductor  transversus  and  first  dorsal  interosseous;  dim,  dorsal  interosseous 
membrane;  FLP,  flexor  longus  po'licis  in  its  synovial  sheath;  HM,  hypothenar  muscles  with 
intermuscular  spaces;  iv,  interosseous  vessels  and  nerves. 


the    pus   by  appropriate  incisions  and  apply  hyperaemia  by  Klapp's  suction 
metftod  which  has  given  the  author  very  gratifying  results. 

Incised  v/ounds  of  the  hand  must  be  treated  on  ordinary  surgical  principles; 
tendons,  if  divided,  must  be  repaired  and  cleanliness  sought.  Many  wounds 
of  the  hands  are  very  much  lacerated  and  have  much  dirt  ingrained  into  them. 
Two  methods  of  treatment  are  possible:  (A)  Cleanse  as  thoroughly  as  possible, 
repair  injured  tendons,  close  the  wound,  providing  for  drainage  by  means  of 
rubber  tissue.     If  infection  developes  later,  treat  it.     Bier's  hyperaemia  is  of 


ioi6 


OPERATIONS  FOR  INFECTIVE  LESIONS  OF  THE  HAND. 


r^L^rJi^'SJV^USi 


Fig.  1 195. — {Kanavel.) 
Cross  section,   through  distal  part  of  thenar  area.     See  Fig.  1194  for  common  lettering 
ITS,  indefinite  thenar  spaces;  tmf,  tendon  of  middle  finger;  tm,  thenar  muscles;  pf,  palmar 
fascia;  ra,  radial  artery;  dpa,  deep  palmar  arch — digital  branches  beginning;  dia,  dorsalis 
indicis  artery. 


Fig.   1196.- — {Kanavel.) 


Fig.  1 197. — {Kanavel.) 


WOUNDS. 


IOI7 


muc±L  value  in  warding  off  the  consequences  of  infection.  (B)  Cleanse  the 
wound  as  thoroughly  as  possible.  Swab  the  wound  with  spirits  of  turpentine 
which  may  act  in  three  ways:  (a)  as  a  solvent  of  grease,  (b)  as  an  antiseptic, 
(c)  as  an  excitant  of  local  leucocytosis.  Pack  the  wound  loosely  with  gauze. 
Apply  abundant  moist  dressings  loosely.  Apply  Bier's  constrictor  to  produce 
hyperasmia.  Immobilize.  Immobilization  is  of  special  importance  to  prevent 
spreading  of  infection.      George  Gray  (who  has  unusual  experience  in  the 


Fig.  1 198. — {Kanavel.) 


treatment  of  filthy  lacerated  wounds  of  the  hand)  treats  his  patients  as  above, 
and  after  the  lapse  of  about  forty-eight  hours,  if  infection  has  not  developed, 
removes  the  dressings,  repairs  injured  tissues,  and  closes  the  wound,  providing 
for  drainage  by  means  of  rubber  tissue. 

Infection  has  entered  through  a  wound  in  the  finger.  Suppuration  has 
taken  place.  How  ought  the  principles  of  treatment  outlined  in  the  preceding 
pages  be  carried  out? 

Make  the  first  incision  at  the  site  of  known  infection.     Open  the  tendon 


IOl8  OPERATIONS    FOR   INFECTIVE    LESIONS    OF   THE  HAND. 

sheath,  if  involved,  at  the  side.  This  applies  to  the  middle  and  proximal 
phalanges.  Do  not  cut  the  tissues  over  an  articulation  unless  it  is  necessary  to 
drain  the  joint.  If  necessary  incise  on  both  sides  of  the  finger.  If  the  infection 
involves  the  palmar  end  of  the  sheath  but  has  evidently  not  spread  further,  incise 
in  the  middle  line  "from  the  flexion  crease  at  the  base  of  the  proximal  phalanx 
for  about  three-fourths  of  an  inch  into  the  palm.  If,  however,  there  is  some 
question  whether  the  lumbrical  spaces  at  the  side  have  begun  to  be  involved 
the  incision  is  made  upon  the  side  most  affected,  opening  the  space  and  the  ten- 
don sheath  at  the  same  time."  WTien  the  index  finger  is  affected  and  the  in- 
fection has  passed  into  the  lumbrical  space  on  the  radial  side,  then  it  may 
extend  into  the  thenar  space.  Under  these  circumstances  incise  so  as  to 
open  the  tendon  sheath  and  lumbrical  space  just  external  to  the  tendon — 
find  if  pus  is  present  in  the  thenar  space.  If  pus  is  present  continue  the 
incision  parallel  to  and  on  the  radial  side  of  the  metacarpal  of  the  index 
finger.  This  cut  must  run  dorsal  to  the  web  of  the  thumb.  Through  the 
wound  push  a  sinus  forceps  (hemostat)  (Fig,  1198)  across  the  palmar  surface  of 
the  metacarpal  bone  into  the  thenar  space.  Open  the  blades  of  the  forceps  to 
enlarge  the  deep  wound.  Provide  rubber  tissue  drainage.  By  the  above 
means  the  deep  palmar  space  is  drained  without  the  palm  being  incised  and  with- 
out danger  to  the  palmar  arches.  When  introducing  the  forceps  do  not  force 
its  point  beyond  the  middle  metacarpal,  as  it  then  would  penetrate  and  probably 
infect  the  mid-palmar  space.  When  the  middle  finger  is  infected  and  the 
trouble  preads  upwards,  the  mid-palmar  space  becomes  involved.  Incise  to  the 
ulnar  side  of  the  tendon  from  the  flexion  crease  at  the  base  of  proximal 
phalanx  for  about  3/4  inch  into  the  palm.  If  pus  can  be  pressed  from  the  palm 
into  the  wound  pass  a  closed  sinus  forceps,  at  a  deeper  level  than  the  tendons, 
so  as  to  penetrate  and  provide  drainage  for  the  mid  palmar  space.  It  is  easy 
to  open  the  mid-palmar  space  from  the  ulnar  side  of  the  flexor  tendon  of  the 
ring  finger  by  pushing  a  .forceps  upwards  and  inwards  under  the  tendons 
(Fig.  I I 98). 

Of  course  infection  may  extend  from  any  of  the  fingers  to  the  palmar  synovial 
sheaths,  but  is  very  much  more  liable  to  do  so  from  the  little  finger  whose 
flexor  sheath  is  continuous  with  the  palmar  sheath  (ulnar  bursa)  in  50  per  cent, 
of  the  cases  or  from  the  thumb  (Figs.  1189,  1190,  and  1191),  whose  tendon 
sheath  extends  from  the  distal  phalanx  to  the  palmar  sheath  (radial  bursa)  and 
above  the  annular  ligament  of  the  wrist  in  95  per  cent,  of  the  cases.  When 
there  is  grave  infection  of  the  ulnar  bursa  very  free  drainage  is  necessary.  The 
following  method  (Kanavel's)  fulfills  the  requirements  with  the  minimum  of  in- 
jury to  important  structures. 

Incise  at  the  point  of  infection  and  there  open  the  tendon  sheath.  Press 
the  palm,  if  it  is  involved,  pus  will  come  into  the  wound.  Incise  at  the  distal 
flexion-crease  of  the  palm  and  enter  the  tendon  sheath.  Pass  a  director  up  the 
sheath  into  the  palm.  Guided  by  the  director  open  the  ulnar  bursa,  cutting  to 
the  ulnar  side  of  the  tendons.     "Having  arrived  at  the  anterior  annular  liga- 


INFECTIOUS    H.A.XD. 


IO19 


ment,  pressure  above  over  the  prolongation  of  the  sheath  in  the  forearm  will 
force  pus  downwards  into  the  sheath  below  the  ligament  if  the  infection  has 
extended  here,  as  it  generally  has.    If  it  is  very  early  in  the  course,  it  may  be  justi- 
fiable to  leave  the  anterior  annular  ligament  intact  and  incise  the  sheath  above 
the  ligament  on  the  same  line.     This  line  here  lies  about  one-half  inch  to  the 
radial  side  of  the  ulnar  artery.     Generally,  however,  the  swelling  is  such  that 
the  pulsation  of  this  vessel  cannot  be  felt.     It  is  then  necessary  to  proceed  by 
choosing  a  point  at  the  junction  of  the  middle  and  ulnar  thirds  of  the  flexor 
surface  and  incising  carefully,  layer  by  layer,  until  the  group  of  flexor  tendons 
is  reached.     These  can  be  identified  by  moving  the  fingers.     The  dissection 
is  now  carried  down  along  the  ulnar  border  of  these  tendons  in  juxtaposition 
to  them  and  immediately  above  the  anterior  annular  ligament,  since  the  sheath 
lies  to  the  ulnar  side  and  posterior  to  the  tendons.     If  infected  it  should  be 
freely  opened,  since  the  swelling  due  to  oedema  and  inflammatory  infiltration 
tends  to  a  close  small  opening.     If  the  infection  is  now  seen  to  be  at  all  severe, 
the  anterior  annular  ligament  is  split  as  far  to  the  ulnar  side  as  possible.     The 
hook  of  the  unciform  interferes  somewhat  with  the  incision.     If  it  is  determined 
at  first  when  the  palmar  part  is  incised  that  the  infection  is  at  all  severe,  I  pro- 
ceed differently.     The  incision  is  continued  from  below  upwards  at  once  cutting 
the  anterior  ligament  and  carrying  the  incision  about  an  inch  up  on  the  forearm. 
This  latter  is  made  as  much  to  drain  the  subcutaneous  area  above  the  wrist, 
which  commonly  becomes  infected,  as  to  open  the  sheath.     This  incision  is 
always  supplemented  by  a  transverse  drainage  above  the  wrist-joint  as  follows: 
At  a  point  about  i  i  /2  inches  above  the  tip  of  the  ulna  an  incision  is  made  directly 
down  on  this  bone  at  its  flexor  surface;  an  artery  forceps  is  now  thrust  across 
the  flexor  surface  of  this  bone  and  the  radius  until  it  impinges  on  the  skin  at  the 
radial  side,  where  the  knife  cuts  down  upon  it.     The  incisions  in  the  skin  are 
now  enlarged  to  the  length  of  an  inch  and  a  half  or  more  and  with  the  artery 
forceps  the  subtendinous  area  to  the  same  extent.     Especial  care  should  be 
used  here  to  make  the  incision  neither  too  far  upon  the  flexor  surface  nor  dorsally, 
since  in  the  first  instance,  especially  upon  the  radial  side,  the  artery  may  be 
injured  either  by  the  primary  incision  or  subsequent  necrosis,  and  in  the  second 
instance,  if  the  incision  is  too  far  dorsal,  it  will  not  drain  easily.     If  the  primary 
incision  is  made  low  down  and  on  the  radial  side  the  danger  of  injuring  the  radial 
is  greater.     With  the  proper  precaution,  no  anxiety  need  be  felt  (Fig.  1197). 
Having  opened  this  area  the  finger  is  now  inserted  under  the  flexor  profundus 
tendons  and  if  there  is  any  infection  of  the  sheath  it  is  bulging  and  can  be  opened 
easily.     In  case  it  is  not  found  easily,  flexion  and  extension  of  the  fingers  will 
locate  the  tendons  involved  and  the  palpating  finger  is  pushed  up  among  them, 
or  an  artery  forceps  can  be  pushed  down  from  the  bursa  which  has  been  opened 
in  front.     Its  point  is  felt  plainly  by  the  finger  and  the  opening  dilated  freely. 
As  a  matter  of  fact,  the  infection  will  be  found  to  have  ruptured  into  this  space 
in  practically  every  case,  except  in  the  very  earliest  stages.     I  wish  to  emphasize 
that  it  is  this  incision  that  I  depend  on  for  drainage  of  the  upper  end  of  the  bursa, 


I020  OPERATIONS    FOR    INFECTIVE    LESIONS    OF    THE   HAND. 

since  it  extends  upwards  on  the  tendons  on  their  posterior  surface.  I  have  even 
made  it  in  cases  where  I  had  made  no  incision  upon  the  flexor  surface  of  the 
forearm,  or  had  deemed  it  advisable  to  cut  the  anterior  annular  ligament. 
Particularly  in  infections  of  the  radial  bursa  do  I  do  this.  In  other  words, 
I  use  it  as  a  site  for  entering  and  draining  the  sheath  before  rupture  as  well  as 
the  site  for  incision  for  draining  the  extension  into  the  forearm." 

When  there  is  grave  infection  of  the  thumb  and  radial  bursa,  Kanavel 
operates  as  follows:  "Here  it  is  my  habit  to  dissect  down  to  the  tendon  upon 
the  flexor  surface  of  the  proximal  phalanx;  having  entered  the  sheath,  the 
incision  is  enlarged  along  the  sac  through  the  thenar  eminence  separating  the 
muscular  mass  (heads  of  the  flexor  brevis  pollicis).  It  should  be  remembered 
that  the  tendon  lies  nearer  the  palm  than  one  would  be  inclined  to  think  and 
that  the  mass  of  the  thenar  muscles  lies  to  the  radial  side  of  the  incision.  This 
is  only  carried  up  to  within  a  thumb's  breadth  of  the  lower  border  of  the  anterior 
annular  ligament,  since  I  have  previously  shown  by  observations  made  upon 
cadaver  hands  and  reported  in  an  earlier  contribution  that  the  motor  nerve 
to  the  thenar  muscles  passes  across  the  sheath  between  this  point  and  the 
lower  edge  of  the  anterior  annular  ligament,  and  in  my  opinion  loss  of  the 
flexor  longus  pollicis  tendon  is  to  be  preferred  to  destroying  this  nerve,  and 
thus  bringing  about  a  loss  of  the  muscles  which  it  supplies.  The  incision 
begins  again  at  the  upper  part  of  the  anterior  annular  ligament,  opening  the 
proximal  end  of  the  radial  bursa  above  this  ligament.  If  the  process  is  severe 
and  there  is  fear  that  the  sheath  may  have  ruptured,  incisions  are  made  laterally 
above  the  wrist-joint  as  described  under  the  ulnar  sheath  infection  and  the 
tendon  sheath  drained  from  this  site.  Exceptionally  incision  upon  the  radial 
side  alone  may  be  sufhcient.  If  the  anterior  incision  is  made,  subcutaneous 
pus  may  be  found,  leading  to  the  mistaken  notion  that  the  sheath  has  ruptured 
and  is  draining  into  this  area.  One  should  not  be  deterred  from  continuing 
the  incision,  going  a  quarter  of  an  inch  to  the  radial  side  of  the  median  line  of 
the  flexor  surface  of  the  forearm.  The  dissection  is  carried  down  to  the 
radial  side  of  the  flexor  sublimis  tendons,  avoiding  the  median  nerve  in  the 
floor  and  to  the  ulnar  side.  The  tendon  sheath  has  generally  ruptured  by  this 
time  or  can  be  identified  by  a  grooved  director  or  fine  probe  passed  from  the 
opened  sheath  below.  It  is  entirely  safe  to  cut  the  upper  part  of  the  anterior 
annular  ligarr en t  (Fig.  1197). 

If  the  infection  has  shown  any  tendency  to  be  virulent  or  extend  rapidly 
I  feel  that  this  anterior  incision  should  be  limited  to  opening  the  subcutaneous 
accumulation,  if  there  be  any,  and  the  tendon  sheath  should  be  opened  by 
the  lateral  incisions  described  above,  for  entering  the  space  between  the 
flexor  profundus  tendons  and  the  pronator  quadratus.  Good-sized  incisions 
should  be  made  so  that  drainage  may  be  free.  In  many  cases  where  the 
infection  has  been  severe  or  the  tendon  impaired,  primary  removal  of  the 
tendon  should  be  favored.  This  is  particularly  liable  to  die  and  remain  for 
many  weeks  causing  the  infection  to  persist  and  jeopardize  other  structures, 


INFECTIOUS    HAND.  I02I 

SO  that  I  make  it  a  rule  if  the  tendon  is  at  all  destroyed  or  the  infection  shows  a 
slow  recovery  to  remove  the  tendon  at  once.  I  am  also  especially  inclined  to 
do  this  if  the  ulnar  bursa  has  so  far  escaped  involvement,  since  the  preservation 
of  this  is  particularly  to  be  sought." 

The  use  of  drainage-tubes  is  to  be  condemned.  They  are  unnecessary 
if  the  incisions  have  been  properly  made,  and  are  always  liable  to  cause  necrosis 
of  tendons.  Gauze  strips  are  useless  and  act  as  plugs  preventing  drainage. 
It  is  easy  to  keep  the  wounds  sufficiently  open  by  means  of  strips  of  rubber 
tissue  or  oiled  silk.  If  these  materials  are  not  available,  then  gauze  strips 
ivell  smeared  with  vaseline  or  some  sterile  unguent  will  serve  the  same  purpose. 
The  dressings  must  be  voluminous  and  not  tight.  The  use  of  a  dorsal  splint 
is  valuable.  Bier's  hyperjemia  is  an  invaluable  therapeutic  aid  and  ought 
never  to  be  forgotten. 


CHAPTER  CV. 
WOUNDS  OF  JOINTS. 

1.  Punctures. 

(A)  The  patient  is  seen  promptly.  Clean  the  skin  thoroughly.  Apply 
dressings;  cover  with  a  liberal  supply  of  cotton  to  permit  even,  elastic  pressure. 
Immobilize  by  means  of  splint  and  starch  (crinoline)  bandages  or  of  plaster 
of  Paris.  Elevate  the  limb.  Carefully  watch  temperature,  pulse,  and  pain 
for  a  few  days. 

(a)  If  all  goes  well  begin  motion  in  about  ten  days.  The  elastic  pressure 
usually  suffices  to  assist  nature  in  removing  the  eflfusion  which  always  appears. 
Sometimes  if  the  effusion  is  great  puncture  or  aspiration  is  necessary.  If 
the  temperature  reaches  ioo°  and  the  pulse  90-100  during  the  first  twenty- 
four  hours  after  the  accident,  and  especially  if  pain  is  not  severe  and  throbbing, 
grave  alarm  need  not  be  felt. 

(b)  If  the  temperature  and  pulse  run  higher,  if  pain  is  a  prominent  symptom 
and  if  there  is  any  hint  of  a  chill,  infection  is  present.  There  has  been  no 
time  for  any  great  increase  in  the  number  of  bacteria  present,  but  along  with 
those  introduced,  toxins  have  entered,  and  the  parts  have  begun  to  react  to 
the  insult.  The  joint  is  sv/ollen,  red,  etc.  Vigorous  and  immediate  treatment 
must  be  adopted.  Arthrotomy  with  drainage  is  calculated  to  give  good 
results.     Bier's  hyperaemia  may  be  valuable. 

(B)  (a)  The  patient  is  seen  several  days  after  an  injury  which  has  been 
neglected  or  inefficiently  watched.  The  signs  of  arthritis  are  present —  fever, 
acute  and  increasing  pain,  effusion,  redness,  and  perhaps  lymphatic  involve- 
ment. Perform  arthrotomy  at  once.  Drain.  As  soon  as  possible  remove 
the  drain  and  begin  motion,  (b)  Severe  advanced  infection  requires  the  most 
free  drainage  possible  and  possibly  resection. 

2.  Incised  Wounds. — Enlarge  if  necessary.  If  required  for  inspection, 
cleansing,  or  drainage,  make  supplementary  incisions.  Clean.  Provide 
efficient  drainage. 


1022 


CHAPTER.  CVI. 

INDICATIONS.     JOINTS. 

It  is  difficult  or  impossible  to  lay  down  absolute  rules  regarding  operative 
interference  in  many  cases  of  articular  disease,  but  a  few  remarks  on  the 
subject  may  be  of  value  to  the  junior  surgeon. 

(A)  Wounds  of  the  Joints.     (See  preceding  chapter.) 

(B)  Simple  hydrops  articuli,  generally  of  traumatic  origin.  Only  if 
the  effusion  is  great  and  resistant  to  treatment  by  pressure,  etc.,  does  it  become 
proper  to  aspirate  and  possibly  to  inject  some  modifying  fluid,  such  as  a  5  per 
cent,  solution  of  carbolic  acid  or  2  per  cent,  formalin-glycerine.  If  the  hydrops 
is  due  to  the  presence  of  a  foreign  body  (rice  body)  or  its  equivalent,  e.  g., 
displaced  semilunar  cartilage,  treatment  must  be  directed  against  the  exciting 
cause. 

(C)  Arthritis  from  Pyogenic  Infection. — (I)  The  arthritis  is  not  very 
acute;  the  general  symptoms  are  not  menacing  in  character;  the  general 
condition  of  the  patient  is  good.  Use  absolute  rest  plus  some  active  conserva- 
tive treatment,  e.  g.,  Bier's  hyperaemia,  or  puncture  the  joint,  withdraw  the 
fluid,  douche  with  salt  solution,  and  inject  Murphy's  formahn-glycerine  solu- 
tion.    Watch  the  case  carefully  lest  more  vigorous  measures  may  be  necessary. 

(2)  The  arthritis  is  more  acute  or  is  accompanied  by  menacing  symptoms, 
but  yet  the  patient  is  not  in  an  alarming  condition. 

Open  the  joint  sufficiently  to  provide  free  drainage,  irrigate,  introduce 
drainage-tubes.  According  to  circumstances  apply  suction  to  the  parts  by 
means  of  the  Bier-Klapp  cups  (this  assists  drainage  and  provides  hyperemia), 
or  apply  Bier's  rubber  bandage  to  produce  obstructive  hyperaemia  and  hinder 
absorption. 

(3)  The  arthritis  is  very  extensive  and  progressive.  Provide  the  most  free 
drainage  possible,  lay  the  joint  open  as  thoroughly  as  possible  and  keep  it 
open  so  that  no  retention  of  discharges  may  be  possible  (Bier's  obstructive 
hyperaemia  may  benefit).  Do  not  fear  injury  to  the  subsequent  function  of 
the  joint,  the  operation  is  a  life-saving  one  and  no  thoughts  of  subsequent 
disabilities  must  be  permitted  to  interfere  with  the  providing  of  thorough 
drainage.     Resection  of  the  joint  may  be  necessary. 

(4)  The  patient's  general  condition  is  poor  from  age,  continued  disease, 
etc.  He  will  be  unable  to  withstand  a  long  illness.  Amputation  is  the  treat- 
ment of  choice.  In  a  few  cases,  e.  g.,  in  the  hip,  resection  of  the  joint  may 
give  better  prospects  of  recovery  than  amputation. 

(5)  The  arthritis  is  the  result  of,  or  is  complicated  by  osteomyelitis.     The 

102^ 


I024  INDICATIONS.       JOINTS. 

treatment  must  be  a  combination  of  that  for  the  bone  lesion  and  of  arthrotomy. 
Atypical  or  typical  excision  of  the  joint  will  probably  be  indicated. 

(D)  Tuberculous  Arthritis. — The  indications  for  treatment  depend, 
(a)  on  the  general  condition  and  social  position  of  the  patient;  (b)  on  the  local 
lesions  present. 

(a)  The  General  Condition  and  Social  Position  of  the  Patient. — 
Conservative  treatment  gives  its  best  results  in  childhood  and  youth,  during 
which  periods  the  loss  of  time  involved  is  of  comparatively  small  importance. 
The  old  and  feeble  require  treatm.ent  which  will  give  the  quickest  possible 
relief  with  the  least  tax  on  their  vitality.  In  youth  it  is  more  important  to 
obtain  a  functionally  useful  joint  than  to  save  time;  among  the  aged  and 
debilitated  prompt  recovery  is  more  important  than  functional  recovery. 
The  presence  of  visceral  tuberculosis  or  of  amyloid  disease  spells  amputation 
in  most  instances,  though  to  this  there  are  exceptions.  Amputation  often 
leads  to  improvement,  sometimes  to  cure,  of  the  internal  lesions. 

(b)  Local  Lesions. 

(i)  Non-suppurative  Tuberculous  Arthritis. — In  every  case  begin  by 
using  conservative  treatment,  viz.,  rest  with  immobilization;  Bier's  hyperaemia; 
aspiration  with  injection  of  some  modifying  solution  if  hydrops  is  present. 

If  after  a  reasonable  time  (months)  there  is  no  improvement,  if  pain  persists, 
if  deformities  develop,  operation  must  be  considered.  When  skiagraphy 
shows  the  presence  of  severe  osseous  lesions,  conservative  treatment,  while 
it  may  succeed,  yet  is  not  so  likely  to  do  so.  If  the  bone  lesions  do  not  com- 
municate with  the  joint,  if  they  can  be  removed  without  opening  the  joint  and 
without  injury  to  an  active  epiphyseal  cartilage,  then  it  is  wise  to  excise  the 
diseased  foci.  In  deciding  between  operative  and  non-operative  treatment, 
take  into  consideration  the  individual  joint  affected,  and  the  amount  of  handicap 
anchylosis  of  that  articulation  would  impose  on  the  patient. 

(2)  Suppurative  tuberculous  arthritis  without  fistula.  (No  pyogenic 
infection  is  present.     The  disease  is  a  cold  abscess  of  the  joint.) 

Combined  with  immobilization,  the  treatment  consists  in  aspiration  followed 
by  injections  of  iodoform.  Iodoform  in  oil,  glycerine,  ether,  or  in  formalin 
and  glycerine.)  The  results  obtained  are  better  in  children  than  in  adults, 
because  in  the  latter  sequestra  are  usually  present.  Instead  of  aspirating  one 
may  incise  the  joint,  mop  it  with  gauze,  douche  with  salt  solution,  rub  the 
joint  surfaces  with  iodoform  or  with  tincture  of  iodine,  close  the  wound  with 
sutures,  fill  the  joint  cavity  with  iodoform  emulsion  before  tightening  the  last 
sutures.  Bier  never  uses  iodoform  injections  except  in  tuberculous  hydrops  or 
in  cases  of  large  cold  abscesses  which  fill  the  articular  cavities;  in  these  hyperaemia 
is  out  of  place.  Under  other  circumstances  Bier  evacuates  the  pus  and  treats 
by  means  of  hypersemia.  Small  multiple  cold  abscesses  around  a  joint  are 
suitable  for  puncture  and  suction  hyperaemia.  If  improvement  under  conserva- 
tive measures  does  not  manifest  itself  in  a  reasonable  time,  or  if  the  disease 
shows  progress,  one  must  resort  to  operation — usually  typical  or  atypical 
resection. 


ARTHRITIS.  1025 

(3)  Suppurative  Tuberculous  Arthritis  with  Fistulae. — This  means 
that  secondary  infection  is  present  as  a  complication. 

(a)  The  disease  is  not  progressing  rapidly.  On  probing  no  dead  or  diseased 
bone  is  felt.  Clean  the  fistula  with  gauze  wicks  or  with  a  curette.  Use  suction 
hyperaemia.  Sometimes  vigorous  suction  may  take  the  place  of  the  curette. 
Treat  the  main  diseaes  by  the  usual  conservative  means.  If  diseased  bone  is 
found  at  bottom  of  the  fistula,  this  must  be  exposed  and  removed. 

(b)  Instead  of  treating  in  the  preceding  manner,  cleanse  the  fistula,  re- 
move any  loose  sequestra,  fill  the  fistula  by  injecting  into  it  Beck's  bismuth 
vaseline  or  his  bismuth  paste.     This  frequently  leads  to  recovery. 

(c)  The  above  measures  fail  or  the  disease  appears  progressive.  Symptoms 
are  such  that  loss  of  time  is  dangerous.  Perform  either  typical  or  atypical  re- 
section. Garre  makes  a  valuable  protest  against  carelessness  in  the  treatment 
of  tuberculous  arthritis.  Unless  the  fistulas  are  kept  clean  and  well  protected 
by  dressings,  and  unless  the  soiled  dressings  are  sterilized  or  destroyed,  the 
patient  becomes  a  menace  to  the  community. 

(4)  The  presence  of  multiple  lesions  at  different  parts  of  the  same  limb 
generally  demands  amputation,  though  even  here  general  treatment,  plus 
local  care,  often  leads  to  cure  in  children. 

As  75  per  cent,  of  cases  of  tuberculous  arthritis  may  be  cured  by  conserva- 
tive means  (Hoflfa),  do  not  lightly  turn  to  operation.  Remember  that  the 
rules  guiding  the  surgeon  in  his  choice  of  treatment  vary  according  to  the 
social  status  of  the  patient,  his  means  to  indulge  in  prolonged  treatment,  etc., 
and  according  to  the  joint  involved. 

(E)  Gonorrhoeal  Arthritis. — Conservative  treatment  is  generally  sufficient. 
Bier's  hyperaemia  is  said  to  be  most  valuable.  In  hydrops  articuli  and  in 
sero-fibrinous  arthritis,  if  the  above  measures  do  not  give  relief  promptly, 
it  is  proper  to  aspirate  and  inject  some  modifying  solution,  e.  g.,  5  per  cent, 
carbolic  acid  solution.  In  suppurative  arthritis  incision  and  drainage  are 
necessary.  Whatever  means  of  treatment  is  adopted,  beware  of  anchylosis 
and  deformities  from  contracture. 

(F)  Typhoidal  Arthritis. — It  is  extremely  rare  that  typhoidal  arthritis 
leads  to  suppuration;  when  it  does  then  incision  and  drainage  are  necessary. 
Hydrops  of  typhoidal  origin,  when  present,  is  liable  to  cause  dislocation  especial- 
ly of  the  hip,  hence  aspiration  is  proper. 

(G)  Acute  Rheumatic  Arthritis. — O'Connor,  of  Buenos  Ayres,  is  en- 
thusiastic over  the  benefits  to  tbe  obtained  from  incision,  irrigation,  and  drainage 
of  whatever  joints  are  affected.  He  believes  that  under  this  treatment  the 
local  lesions  recover  promptly,  pain  is  relieved  at  once,  and  secondary  heart 
troubles  are  avoided.  The  author  has  no  experience  in  the  matter,  but 
O'Connor's  arguments  seem  plausible  and  well  backed  by  results. 

(H)  Pneumococcal  Arthritis. — The  indications  are  the  same  as  in 
ordinary  pyogenic  infections  of  the  joints. 

(I)  Traumatic  Dry  Arthritis — Rovsing  finds  that  injections  of  sterile 
vaseline  exercise  a  favorable  influence  in  this  painful  and  disabling  disease. 
6S 


CHAPTER  CVII. 
AMPUTATION  OR  DISARTICULATION. 

Esmarch  gives  the  following  indications  for  amputation: 

1.  Extensive  comminution  of  the  bones  and  laceration  of  large  vessels 
and  nerves. 

2.  Extensive  destruction  of  the  whole  musculature  of  a  region  even  when 
the  bones  are  not  much  damaged. 

3.  Very  extensive  destruction  of  skin  (ulcer,  burns)  if  the  limb  is  rendered 
useless  by  it  and  repair  by  skin  transplantation  is  impossible. 

4.  Gangrene. 

5.  Malignant  tumors. 

6.  Severe  septic  or  pyasmic  infection  when  removal  of  the  focus  is  impossible 
by  other  means. 

7.  Suppuration  of  long  duration  when  the  patient's  strength  is  so  lowered 
that  it  is  evident  he  cannot  withstand  a  long  illness  and  that  by  amputation 
he  is  likely  to  recover  in  a  short  time. 

8.  Amputation  of  choice.  When  the  patient  desires  to  be  rid  of  a  useless 
organ,  e.  g.,  an  atrophied  or  paralyzed  limb. 

When  amputation  is  necessitated  by  gangrene,  when  ought  one  to  operate  ? 
Immediate  amputation  is  called  for  because  the  patient  is  constantly  absorbing 
poisons  from  the  diseased  part  and  is  constantly  losing  strength.  Immediate 
amputation  is  improper  because  one  does  not  know  where  to  operate;  one 
does  not  know  where  the  gangrenous  process  will  stop  and  hence  too  much 
of  the  limb  may  be  sacrificed  or,  what  is  more  serious,  too  little  may  be  removed 
and  gangrene  may  appear  in  the  stump.  It  has  been  exceedingly  difficult 
to  decide  this  question  in  the  past;  if  intoxication  were  great  it  was  wise  to  run 
chances  of  recurrence  and  amputate;  if  intoxication  were  not  severe  and  the 
patient's  strength  permitted,  it  was  wise  to  delay  until  the  line  of  demarcation 
became  evident.  Mozkowicz("LaPresseMed.,"  Oct.  24, 1906)  has  endeavored, 
apparently  successfully,  to  find  where  the  line  of  demarcation  will  form 
in  any  given  case,  i.  e.,  to  determine  the  seat  of  arterial  obliteration.  His 
method  is  the  following:  Elevate  the  limb  for  two  or  three  minutes.  Apply 
an  elastic  constrictor  high  up  the  limb  as  if  for  amputation  and  lower  the 
limb  to  the  table.  After  five  minutes  remove  the  constrictor  quickly.  In 
health  the  arterial  circulation  re-establishes  itself  at  once,  a  hyperaemic  flush 
passes  down  the  limb  and  reaches  the  toes  in  about  two  seconds.  If  gangrene 
is  present  the  ruddy  flush  rapidly  passes  a  certain  distance  down  the  limb 
then  pauses  so  that  there  is  a  clear  line  of  demarcation  between  the;  skin  above 

1026 


WHERE    TO   AMPUTATE.  IO27 

(hypercTemic)  and  that  below  (ischaemic)  then  the  flushing  passes  slowly  down- 
ward, taking  minutes  instead  of  seconds  to  reach  the  toes.  The  line  where 
the  descending  flush  pauses  corresponds  to  the  site  of  arterial  obliteration  and 
to  the  limit  which  the  gangrenous  process  may  be  expected  to  reach.  Several 
surgeons,  notably  v.  Eiselsberg,  have  corroborated  Moskowicz's  observations. 

Van  Buren  Knott,  when  amputating  in  certain  bad  cases  of  gangrene  or 
analogous  septic  conditions,  considers  it  of  prime  importance,  first,  to  be 
rapid,  and,  secmid,  to  avoid  interference  with  the  nutrition  of  the  tissues  to  be 
preserved.  He  fulfills  these  conditions  by  making  a  circular  amputation; 
dividing  the  skin,  the  muscles,  the  bone  at  the  same  level,  attending  to  hemo- 
stasis,  applying  dressings  and  then  waiting  until  recovery  has  so  far  taken 
place  that  it  is  safe  to  fashion  the  stump  and  di\ade  the  bone  at  a  higher  level. 
At  the  primary  operation  there  is  no  reflection  of  the  tissues,  no  separation  of 
one  tissue  plane  from  another,  no  application  of  sutures  and  the  ligatures  are 
applied  to  the  vessels  as  precisely  as  possible  so  as  to  avoid  strangulation 
of  surrounding  structures. 

When  the  lesion  necessitating  amputation  is  old  suppurative  disease, 
sinuses  in  the  tissues  forming  the  flaps  do  not  appear  to  do  much  harm  if  they 
are  well  cleaned  by  dissection,  curettement,  and  chemical  disinfection  (H. 
Barnard).     Recognition  of  this  fact  tends  to  conservatism. 

When  and  Where  to  Amputate  a  Limb  after  Injury. — W.  L.  Estes 
has  thoroughly  studied  this  question,  his  experience  is  vast  and  his  ideas  are 
well  worth  consideration.  The  following  paragraphs  are  based  on  Estes's 
publication  ("International  Journ.  of  Surg.,"  June,  1905). 

1.  The  aged  and  very  young  are  intolerant  of  long  confinement,  hence 
are  less  suitable  to  conservative  treatment  than  other  individuals.  Chronic 
alcoholics,  diabetics,  nephritics,  etc.,  are  unsuited  to  long-lasting  conservative 
treatment.  Tuberculosis  of  moderate  degree  does  not  seriously  interfere  with 
conservatism.  The  best  subjects  for  conservatism  are  robust  individuals 
of  good  habits  in  early  adult  life  and  children  above  ten  years  of  age. 

2.  Severe  laceration  and  crushes  from  falls  or  blows  over  restricted  areas 
are  more  suitable  for  conservatism  than  when  they  are  due  to  squeezes  or 
pressure  of  heavy  machinery,  hea\'y  stones,  or  car  wheels.  These  latter 
injuries  correspond  more  or  less  to  such  as  are  produced  by  the  angiotribe. 

3.  Thick  muscular  portions  of  a  limb  stand  more  injury  than  thinner 
parts.  Crushes  of  bone  and  muscle  even  where  extensive  admit  of  conserva- 
tive efiforts  if  the  '^skin  is  not  fatally  injured  over  a  considerable  area,  say  half 
of  the  periphery  of  the  limb  at  the  seat  of  injury."  If  the  principal  vessels 
of  the  thigh  or  upper  arm  are  severed  and  laceration  is  extensive^  amputate 
If  in  forearm  only  one  system  of  vessels  and  nerves  is  severed,  e.  g.,  the  radial, 
and  the  skin  is  not  badly  damaged,  try  conservatism.  If  both  radial  and 
vilnar  systems  are  badly  damaged,  amputate.  The  same  principles  apply 
to  the  leg.  - 

4.  Psychical  shock  due  to  profound  nervous  distm-bance  from  fear  or  hx>r- 


I028  AMPUTATION    OR    DISARTICULATION. 

ror  is  often  improved  under  ether,  and  hence  immediate  amputation  may  be 
performed.  Anaemic  shock  demands  treatment  by  means  of  salt  solution 
(intravenous,  hypodermic,  rectal),  bandaging  of  the  extremities,  vi^arm  bed, 
morphia,  etc.,  and  amputation  must  be  delayed  until  reaction  sets  in,  twelve, 
twenty-four,  or  thirty-six  hours.     Crile's  direct  transfusion  is  useful. 

5.  If  the  physical  condition  is  not  very  bad  and  if  there  is  no  doubt  as  to 
the  necessity  of  amputation,  do  not  delay. 

6.  When  shock  from  the  operation  is  much  feared,  then  Crile's  method 
of  nerve-blocking  (p.  1048)  may  be  valuable. 

7.  When  delay  is  necessary,  hemorrhage  must  be  absolutely  controlled 
and  cleanliness  sought. 

(a)  Amputation  is  inevitable.  Apply  an  elastic  constrictor  (Estes)  over 
already  injured  tissues  just  far  enough  above  the  severed  muscles  and  bones 
to  assure  it  against  slipping.  The  tissues  compressed  by  the  tourniquet  are 
already  so  injured  that  they  must  be  sacrificed  and  hence  the  extra  constriction 
is  harmless.  The  constrictor  does  not  merely  prevent  hemorrhage;  it  also 
prevents  absorption,  a  matter  of  prime  importance  as  disinfection  of  the  lacer- 
ated wound  is  usually  impracticable.  The  constrictor  should  be  left  in  place 
until  after  the  amputation,  a  second  tourniquet  being  applied  at  a  higher  level 
during  the  operation.  The  lacerated  wound  must  be  covered  by  a  large  moist 
antiseptic  dressing.  If  in  spite  of  these  precautions  infection  reaches  above 
the  tourniquet,  immediate  operation  is  imperative. 

(b)  There  is  reasonable  doubt  as  to  the  absolute  necessity  of  amputation. 
Do  not  apply  the  elastic  constrictor  except  temporarily.  Clean  and  disinfect 
the  wound.  Ligate  vessels.  Remove  the  constrictor.  Pack  the  wound 
with  gauze,  if  desirable,  placing  a  sheet  of  perforated  oil  silk  between  the 
gauze  and  the  tissues  to  prevent  adhesion.  Possibly  introduce  one  or  two 
sutures  to  keep  the  packing  in  position.  Apply  voluminous 'dressings  and  a 
splint.  Bandage  snugly.  The  size  of  the  dressings  gives  elasticity  to  the 
pressure  of  the  bandage.  Elevate  the  limb.  After  twenty-four  to  fifty-six 
hours  proper  conservative  operations  or  amputation  may  be  performed. 

8.  If  the  injury  affects  the  fingers  or  hand  the  character  of  the  amputation 
will  depend  to  some  extent  on  the  occupation  or  social  position  of  the  patient, 
e.  g.,  an  irregular,  "nobby"  stump  may  be  of  vast  service  to  a  workman  (Fig. 
1 199);  a  neat,  smooth  one  may  be  far  more  pleasing  to  a  fashionable  lady. 
As  a  rule,  in  the  case  of  the  fingers,  hand,  and  arm,  as  much  of  the  limb  must 
be  saved  as  possible,  in  the  case  of  the  lower  extremity  several  problems  arise. 

(a)  The  patient  can  afford  a  good  artificial  limb.  In  this  case  the  ideas 
of  the  artificial  limb-makers  must  be  consulted.  According  to  them  the  lowest 
favorable  point  for  section  of  the  bones  in  amputation  of  the  leg  is  about  8 
inches  from  the  ground ;  the  highest  point  is  about  four  inches  below  the  lowest 
edge  of  the  patella;  the  lowest  point  for  section  of  the  femur  in  amputation 
of  the  thigh  is  about  3  to  4  inches  above  the  knee-joint,  the  highest  about  5 
inches  below  the  crotch. 


CIRCULAR   AMPUTATION. 


1029 


(b)  The  patient  cannot  afford  a  good  artificial  limb.  As  much  of  the 
limb  must  be  saved  as  is  possible  and  if  possible  a  natural  weight-bearing 
surface  be  provided  for  the  stump  as  in  Chopart's  and  Syme's  amputations. 

(c)  Remember  that  if  amputation  be  done  through  the  upper  third  of  the 
humerus  in  children,  the  bone  left  will  grow  and  form  a  conical  stump  which 
may  require  reamputation.  A  warning  of  this  fact  given  to  the  patient's 
guardians  may  save  the  surgeon's  reputation.  Conical  stump  is  also  liable 
to  develop  after  amputation  through  the  upper  part  of  the  femur  in  children. 

9.  The  dangers  to  life  are  almost  alike  in  amputations  at  any  level  of  the 
arm  and   forearm.     Practically   all    amputations  below  the   knee   are   equal 
in  safety;  above  the  knee  the  higher  the 
amputation  the  greater  is  the  danger. 

The  Character  of  the  Stump. — The 
character  of  the  stump  is  of  importance. 
As  already  stated,  when  the  patient 
cannot  obtain  a  good  artificial  limb  the 
stump  ought,  if  possible,  to  be  covered 
with  skin  and  tissue  already  accustomed 
to  bearing  weight,  and  the  scar  ought 
not  to  pass  over  the  end  of  the  bone. 
If  an  artificial  limb  is  to  be  worn  a 
number  of  experienced  artificial  limb- 
makers   consider   the    best   site   for  the 

scar  to  be  directly  over  the  end  of  the  stump  and  not  at  the  side.  The  prime 
desideratum  is  to  have  the  end  of  the  bone  well  cushioned  with  soft  tissues 
and  to  have  sufficient  length  of  stump  for  the  application  of  the  artificial 
member.  The  osteoplastic  methods  of  amputating  are  well  calculated  to 
produce  good  useful  stumps  but  are  more  suitable  in  cases  when  disease 
rather  than  trauma  necessitates  the  operation. 

Circular  Amputation. — Circular  amputation  is  the  basis  of  all  the  methods 
of  amputating. 

Example:  Amputation  of  the  arm.  Place  the  patient  on  his  back  with 
the  arm  held  well  out  from  the  table.  Apply  an  elastic  constrictor  around  the 
limb  near  the  shoulder. 

Step  I. — Let  the  first  assistant  pull  the  skin  of  the  arm  upwards  as  far  as 
possible.  Note  the  diameter  of  the  limb  at  the  point  chosen  for  section  of 
the  bone.  At  a  distance  below  this  point  equal  to  three-fourths  the  diameter 
of  the  limb  make  an  incision  completely  around  the  limb  through  the  skin  and 
down  to  the  deep  fascia.  Reflect  the  skin  and  superficial  fascia  upwards  for  a 
distance  of  i  to  i  1/2  inches  (Fig.  1200).  At  this  level  make  a  circular  incision 
through  all  the  remaining  soft  parts  to  the  bone. 

Step  2. — (a)  Make  a  circular  incision  through  the  periosteum  at  the  level 
of  the  muscular  wound.  Reflect  the  periosteum  from  the  bone  for  about  1/2 
to  3/4  inch  upwards  and  divide  the  bone  at  this  level.     A  long  oval  anterior 


Fig.  1 199. — (Jacobson.) 


1 030 


AMPUTATION    OR   DISARTICULATION. 


periosteal  flap  is  as  efficient  and  is  more  easily  made.     The  reflected  periosteum 
forms  flaps  to  cover  the  sawed  surface  of  the  bone. 

(b)  Separate  the  muscles  from  the  bone  and  periosteum  up  to  a  point 
about  1/2  to  3/4  inch  above  that  chosen  for  section  of  the  bone.  At  this  level 
divide  the  periosteum  and  reflect  it  downwards.     Divide  the  bone  at  the  chosen 


Fig.  1200. 

level.  The  result  of  this  is  that  the  distal  end  of  the  bone  in  the  stump  is  bare 
Hirsch  and  Bunge  find  that  the  absence  of  the  periosteum  tends  to  the  pro- 
duction of  a  non-tender  stump.  Bunge  for  the  same  purpose  scrapes  out  the 
marrow  near  the  divided  end  of  the  bone.  Experience  in  the  Russo-Japanese 
war  showed  the  benefit  of  the  Hirsch-Bunge  methods. 


o      3      c 


•f-   -'   -V 


Fig.   1 201  A. 

{Bardenheuer.) 


Fig.   i2or  B. 
{Bardenheuer.) 


Step  3.— Look  for  vessels  in  their  normal  locations  and  tie  them.  The 
main  vessels  run  in  the  intermuscular  septa,  but  many  muscular  vessels  also 
require  attention.  Nerve  trunks  ought  to  be  pulled  out  of  their  sheaths  for  a 
short  distance  and  divided;  this  precaution  often  saves  much  after-pain.      To 


AMPUTATION. 


103 1 


prevent  the  formation  of  stump  neuromata  and  to  obviate  the  recurrence  of 
these  painful  neoplasms,  when  they  have  been  excised,  Bardenheuer  ("Deutsche 
Zeitschrift  fiir  Chir.,"  xcvi)  treats  their  divided  ends  in  such  a  manner  as  to 
avoid  leaving  raw  surfaces  in  the  wound.  Figures  1201,  1202,  and  1203  are 
self-explanatory.  Senn,  in  1896,  made  a  similar  recommendation,  viz.,  to 
remove  a  V-shaped  section  of  the  end  of  the  nerve  and  bring  the  surfaces 
together  by  fine  sutures. 

Apply  hot  pads  to  the  wound.  Remove  the  elastic  constrictor.  Bit  by 
bit  remove  the  hot  pad  from  the  wound;  pick  up  with 
forceps  any  bleeding  vessels;  ligate  the  vessels.  Apply 
to  the  woimd  pads  wrung  out  of  hot  water  until  the 
oozing  stops. 

Step  4. — Obliterate  all  dead  spaces  by  means  of 
buried  catgut  sutures  or  by  relaxation  sutures.  Close 
the  skin  wound  by  sutures  converting  the  circular  into 


6--        --6 


Fig.  1202  A. 
{Bardenheuer.) 


Fig.  1202  B. 
{Bardenheuer.) 


Fig.   1203. 
{Bardenheuer.) 


a  transverse  wound.  If  it  is  impossible  to  obliterate  the  dead  spaces,  if 
oozing  is  expected  or  if  asepsis  is  not  sure,  provide  drainage  either  by  tube, 
rubber  tissue,  or  cigarette.     Apply  dressing  and  a  splint. 

Crede  ("Archiv.  fiir  klin.  Chir.,"  xlviii,  514)  advocates  the  abolition  of 
sutures  after  amputation.  In  place  of  them  he  uses  a  sort  of  capeline  bandage 
of  mde-meshed  gauze,  applied  directly  to  the  stump.  After  one  or  two  layers 
of  the  bandage  have  been  applied  it  is  easy  to  see,  through  them,  if  the  edges 
of  the  wound  are  in  correct  apposition  and  if  the  compression  exercised  by 
the  bandage  is  too  severe.     Outside  the  bandage  he  applies  the  usual  dressings" 

When,  owing  to  the  conical  shape  of  a  limb,  it  is  impossible  to  reflect  the 
tissues  upwards  to  a  sufficient  extent  through  the  circular  incision,  it  is  easy 


I032 


AMPUTATION    OR   DISARTICULATION. 


to  make  one  or  two  lateral  incisions  through  the  soft  parts  and  so  facilitate 
the  work  (Fig.  1204).  Thus  we  have  the  racquet  incision  and  amputation  by 
two  equal  flaps.  If,  instead  of  making  the  original  circular  incision  exactly 
transverse,  it  is  made  oblique,  the  result  is  an  oval  incision  or  practically  an 
amputation  by  a  single  flap  and  the  resultant  scar  is  not  over  the  middle  of 
the  stump.  By  means  of  lateral  longitudinal  incisions  (Fig.  1204)  the  oval 
amputation  may  be  converted  into  one  having  two  unequal  flaps. 

When  the  surgeon  desires  to  amputate  by  the  flap  method  he  of  course 
would  never  dream  of  making  the  flaps  in  the  indirect  method  described  above, 
but  would  trace  them  out  directly  and  fashion  them  either  by  cutting  first 
through  the  skin  and  then  through  the  musculature  or  by  transflxion. 

Amputation  by  transfixion  is  performed  as  follows. 

Example,  amputation  of  the  lower  third  of  the  thigh: 


Fig.  1204. 

Bring  the  patient  so  as  to  rest  with  his  buttocks  on  the  lower  edge  of  the 
table.  Have  an  assistant  hold  the  limb  well  free  from  the  table.  Apply  the 
elastic   constrictor  after  elevating  the  limb   to   render  it   anaemic. 

Step  I. — Retract  the  skin  upwards.  At  the  middle  of  one  side  of  the  thigh 
opposite  the  point  where  the  bone  is  to  be  divided,  pass  a  long  amputating 
knife  through  the  limb  immediately  in  front  of  the  femur  and  make  its  point 
emerge  through  the  skin  at  a  place  directly  opposite  the  point  of  insertion 
(Fig.  1205).  Cut  downwards  and  forwards  so  as  to  make  a  flap  of  sufficient 
length  and  thickness. 

Step  2. — Through  the  original  wound  once  more  pass  the  knife,  but  make 
it  go  behind  the  bone.  Cut  downwards  and  backwards  so  as  to  make  a  posterior 
flap  of  sufficient  length  and  thickness. 

Step  3. — Retract  the  soft  parts  for  a  short  distance  up  the  femur.  Make 
a  circular  incision  so  as  to  bare  the  bone  at  the  site  where  it  is  to  be  divided. 
Divide  the  bone  with  a  saw. 

Step  4. — Attend  to  hemostasis.     Close  the  wound  as  already  described. 

How  long  ought  the  flaps  to  be  ?  They  ought  to  be  long  enough  to  cover 
the  end  of  the  bone  without  tension,  for  this  purpose  the  length  of  the  combined 


AMPUTATION. 


1033 


flaps  should  be  equal  to  i  1/2  times  the  diameter  of  the  limb  at  the  point  of 
bone  section. 

A  combination  of  methods  is  sometimes  useful,  e.  g.,  the  skin  and  super- 


FiG.   1205.  —  {Burghard.) 


Fig.   1206. — {Faraheiif.) 

ficial  fascia  may  be  fashioned  into  flaps  and  the  deep  structures  divided  in  the 
circular  fashion. 


I034 


AMPUTATION    OR    DISARTICULATION. 


Example. — Amputation  of  the  leg:  Support  the  leg  free  from  the  table. 
Apply  the  elastic  constrictor. 

Step  I. — With  a  scalpel  trace  out  a  flap  on  the  inner  side  of  the  leg.  The 
incision  outlining  the  flap  begins  in  the  middle  line  in  front  and  ends  at  a  cor- 
responding point  behind  after  running  a  horseshoe-shaped  course  (Fig.  1206). 
Beginning  and  ending  at  the  same  points  trace  out  an  identical  flap  on  the 
outer  side  of  the  leg.  Reflect  these  flaps,  consisting 
of  skin  and  superficial  fascia,  upwards  until  their 
bases  are  reached. 

Step  2. — Make  a  circular  incision  through  the 
muscles  to  the  bone  (Fig.  1207).  It  is  well  to  make 
the  cut  through  the  muscles  posterior  to  the  bone, 
at  a  lower  level  than  that  through  the  anterior 
muscles  so  as  to  allow  for  their  greatest  retraction. 
Divide  the  interosseous  ligament  and  the  periosteum. 
Step  3. — Divide  the  bones  with  a  saw.  Remove 
rather  more  of  the  fibula  than  of  the  tibia.  With 
a  saw  or  bone-cutting  forceps  remove  the  sharp 
angle  formed  by  the  crest  of  the  tibia.  (Treat  the 
periosteum  in  the  manner  described  in  circular 
amputation.) 

Step  4. — Attend  to  hemostasis.     Close  the  wound, 
etc. 

In  cases  of  injury  the  surgeon  may  be  compelled 
to  combine  various  methods  to  suit  the  case.  For 
example:  The  tibia  and  fibula  are  badly  com- 
minuted up  to  a  point  about  6  inches  below  the 
knee;  the  skin,  muscles,  vessels,  etc.,  are  badly 
lacerated  and  contused  to  the  same  level  on  the 
outer  side  of  the  leg,  the  soft  parts  on  the  inner  side 
of  the  leg  are  more  or  less  intact.  The  injury  is 
sufl&cient  to  demand  amputation.  There  is  ample  tissue  to  cover  the  stump  if 
amputation  is  performed  below  the  knee,  but  none  of  the  typical  operations  are 
calculated  to  utilize  the  material  present.  In  our  example  the  surgeon  makes 
a  long  flap  from  the  structures  on  the  inner  and  posterior  sides  of  the  leg  and 
gets  a  good  result.  Much  may  be  done  by  ingenuity  in  obtaining  viable  flaps, 
to  save  a  very  useful  portion  of  a  limb  which  would  otherwise  be  sacrificed. 

In  the  pre-anaesthetic  days  when  haste  was  absolutely  necessary  flap  amputa- 
tions were  especially  favored  as  they  could  be  speedily  accomplished  by  trans- 
fixing the  limb  with  a  very  long  knife  and  cutting  from  within  outwards.  To-day 
any  limb  may  be  amputated  by  means  of  a  scalpel  (preferably  with  a  blade 
2  to  3  inches  long)  and  any  cross-cut  saw,  plus,  of  course,  the  usual  equipment 
of  scissors,  forceps,  etc.  Liston's  bone  forceps  or  a  rongeur  forceps  are  useful 
for  trimming  the  roughnesses  from  the  bone  stump. 


Fig.   1207. — {Farabeuf.) 


SPECIAL   AMPUTATIONS. 


1035 


A  lion-jawed  forceps  is  useful  for  steadying  the  end  of  the  bone  while  an 
additional  slice  is  being  sawed  off,  if  the  line  of  section  was  made  too  low. 

Some  surgeons,  instead  of  dividing  the  bone  after  section  of  the  soft  parts 
has  been  completed,  expose  the  bone  at  the  chosen  place  by  a  longitudinal 
incision,  separate  it  from  its  surroundings,  divide  it  with  the  chisel  or  Gigli 
wire  saw,  and  then  complete  the  section  of 
the  soft  parts. 

When  amputation  is  being  performed 
through  the  leg  or  forearm  it  is  not  always 
easy  to  retract  the  soft  parts  out  of  danger 
from  injury  by  the  saw.  Special  metal 
retractors  have  been  devised  for  this  pur- 
pose, but  a  three-tailed  bandage  suffices 
(Fig.  1208). 

It  would  be  useless  and  wearisome  to 
describe  all  the  methods  of  ordinary  ampu- 
tation. 


Fig.    1208. — {Esmarch  and  Kowalzig.) 


SPECIAL  AMPUTATIONS. 


Upper  Extremity. — Amputation  of  the  Fingers. — Except  when  a  sym- 
metrical hand  is  more  desirable  to  the  patient  than  a  useful  one,  the  absolute 
rule  must  be  to  preserve  as  much  stump  as  possible  as  long  as  that  stump  is 
provided  with  tendons. 

Disarticulation  of  Distal  Phalanx. — Flex  the  phalanx  strongly.  Make 
a  transverse  incision  on  the  back  of  the  finger  into  the  joint  (Fig.  1209).  This 
severs  the  insertion  of  the  extensors.  Divide  the  lateral  ligaments.  From 
each  end  of  the  transverse  incision  make  lateral  incisions  down  to  the  bone  of 
the  phalanx  to  be  removed.  Separate  the  phalanx  from  the  soft  parts  on  its 
palmar  side  (Fig.  12 10)  until  sufficient  of  the  soft  parts  has  been  separated 
to  cover  stump.  Divide  the  palmar  flap  transversely  and  if  necessary  trim 
it.  Attend  to  hemostasis.  Close  the  wound  with  sutures.  The  resulting 
scar  is  dorsal. 

Disarticulation  of  Middle  Phalanx. — Identical  with  the  preceding 

Amputation  through  the  proximal  phalanx  is  a  good  operation,  provided 
that  the  divided  tendons  are  sutured  to  the  contiguous  theca  (J.  D.  Byrant). 
For  division  of  the  bone  of  the  phalanx  Gigli' s  wire  saw  is  preferable  to  bone- 
cutting  forceps  as  the  latter  causes  splintering. 

In  amputating  for  injury  remember  that  any  method  is  good  which  pro- 
vides a  well-covered  useful  stump. 

Disarticulation  at  the  Phalango-metacarpal  or  at  the  Metacarpo- 
carpal  Joints. — Figures  1211,  1212,  1213,  1214,  1215,  1216,  1217,  1218, 
sufficiently  explain  these  operations.  Note  that  none  of  the  longitudinal  inci- 
sions are  made  in  the  palm. 


1036 


AMPUTATION   OR   DISARTICULATION. 


After  metacarpo-phalangeal  disarticulation  the  resultant  stump  is  liable 
to  be  so  prominent  as  to  interfere  with  the  patient  carrying  out  handiwork,  a 
serious  matter  to  certain  classes  of  mechanics.  Figure  1212  shows  how  section 
of  the  distal  end  of  the  metacarpus  overcomes  this  very  real  disability. 

"When  removing  the  metacarpus  of  the  thumb  or  of  the  little  finger  it  is 
of  much  importance  to  preserve  intact  the  short  muscles  of  the  thenar  and 


Fig.  1209. 


Fig.  1210. 


Fig.  1 21 1.- — (Kocher.) 


Fig.  1212. — {Veau.) 


hypothenar  eminences,  because  by  so  doing  a  very  useful  and  movable  stump 
is  obtained,  especially  if  the  bone  is  removed  subperiosteally. 

In  disarticulating  a  finger,  with  or  without  its  metacarpal  bone,  the  trans- 
verse incision  follows  exactly  the  line  of  the  web  of  the  fingers;  incisions  must 
not  be  made  higher  up  in  the  palm"  (Kocher). 

Amputation  at,  or  Disarticulation  of  the  Wrist. — Do  not  make  a  typical 


AMPUTATIONS. 


1037 


Fig.  1213. — (Veau.) 


Fig.  1214. — {Veau.) 


I038 


AMPUTATION    OR   DISARTICULATION. 


amputation  here  if  it  is  at  all  possible  to  save  a  portion  of  the  hand  or  a  movable 
finger. 

Kocher  recommends  an  obliquely  circular  (oval)  incision  so  as  to  form 
a  palmar  flap  (Figs.  1219-1220).  Figures  1224-1225  show  a  method  named 
after  various  surgeons  (Poupart,  Dubrueil,  v.  Walther). 


Fig.   12 1 5. — (Veau.) 


Fig.  12 16. 
(Esmarch  and  Kowalzig.) 


Fig.   1217. 
{Esmarch  and  Kowalzig.) 


Fig.  1218. 
{Esmarch  and  Kowalzig) 


Amputation  through  the  Forearm  Reguires  no  Special  Notice. 

Disarticulation  of  the  Elbow. 

(A)  Circular  Incision.— (i)  Make  a  circular  cut  through  the  skin  and 
superficial  fascia  about  2  inches  below  the  condyles  of  the  humerus.  Reflect 
the  skin  upwards  so  as  to  expose  the  joint. 


DISARTICULATION    ELBOW. 


1039 


(2)  Strongly  extend  the  joint.  Open  the  joint  by  a  transverse  incision  in 
front.     Divide  the  lateral  ligaments. 

(3)  Hyper-extend  the  joint  until  the  olecranon  projects  into  the  wound. 
Divide  the  tendon  of  the  triceps  at  the  tip  of  the  olecranon.  Attend  to  hemosta- 
sis.     Close  the  wound. 

(B)  Kocher's  Method. — (i)  Flex  the  elbow  to  an  angle  of  135°. 


Fig.  1219. 


Fig.  1220. 


Fig.  1221. — {Esmarch  and  Kowalzig.)  Fig.   1222. — {Esmarch  and   Kowalzig.) 

(2)  Make  an  obliquely  circular  (oval)  incision  round  the  limb  (Fig.  1223), 
Anteriorly  the  incision  is  at  the  joint  level  (/.  e.,  just  above  the  level  of  the 
head  of  the  radius),  posteriorly  it  is  a  hand's  breadth  below  the  tip  of  the  olec- 
ranon. 

Estes  justly  criticises  this  incision  by  saying,  "the  soft  tissues  of  the  anterior 
surface  contract  very  markedly,  those  of  the  posterior  not  at  all  or  very  little, 
so  that  a  circular  incision  at  the  elbow  will  become  by  the  contraction  of  the 


I040 


AMPUTATION    OR    DISARTICULATION. 


tissues  an  oval  one  with  a  long  posterior  flap;  it  is  necessary  to  bear  this  fact 
in  mind  so  that  the  posterior  flap  may  be  made  sufl&ciently  long." 

(3)  Reflect  the  posterior  flap,  consisting  of  skin,  fascia  muscle  and  peri- 
osteun  upwards  to  the  posterior  surface  of  the  humerus. 

(4)  Divide  the  ligaments.     Remove  the  limb. 

(5)  Close  the  wound  after  attending  to  hemostasis. 

(C)  Farabeuf  s  operation  is  similar  to  Kocher's  but  he  obtains  his  main 
flap  from  the  front  instead  of  from  behind. 

Amputation  of  the  Arm  Requires  no  Special 
Comment. 

Amputation  at  the  Shoulder- joint  (Disarticula- 
tion).— Methods  of  attaining  hemostasis  before  dividing 
the  vessels: 

(a)  Pressure  by  finger  or  padded  key,  on  the  sub- 
clavian artery.  This  is  unsatisfactory  as  movements 
of  the  shoulder,  necessary  during  the  amputation,  are 
likely  to  interfere  with  its  success. 

(b)  An  elastic  constrictor  applied  above  Wyeth's 
pins,  introduced  as  in  figure  1224.  This  method  acts 
admirably.  If  the  vessels  are  caught  in  forceps  before 
the  joint  is  disarticulated  it  is  always  efficacious. 

(c)  Preliminary  ligation  of  the  subclavian  artery  is 
valuable  in  case  of  large,  vascular  tumor  about  the 
head  of  the  humerus. 

If   the   surgeon   and   his  assistant  use  their  brains 

as  well  as  their  hands,  it  is  easy  to  control  hemorrhage 

in  the  course  of  the  operation.     A  glance  at  Fig.  1225 

shows  the  principal  arteries  which  will  be  encountered. 

(d)  Pass  an  elastic  constrictor  round  the  shoulder  behind  or  proximal 

to  the  coracoid  and  acromion  processes.     To  prevent  slipping,  pass  a  loop 

of  ordinary  bandage  under  the  constrictor  and  have  an  assistant  pull  this 

towards  the  opposite  shoulder.     This  is  a  very  efiicient  method. 

Jacobson  mentions  that  there  are  about  thirty-two  methods  for  disarticu- 
lating at  the  shoulder.  Only  a  few  types  will  be  described  here.  Remember 
that  when  there  is  much  laceration  of  the  shoulder  the  stump  may  be  covered 
by  any  available  viable  skin  and  give  a  good  result. 

Remember  also  that  it  is  imperative  when  amputating  for  malignant  dis- 
ease, to  sacrifice  too  much  rather  than  too  little,  and  that  if  all  the  tissues  which 
are  usually  employed  to  cover  the  stump  have  been  removed,  it  is  easy  to  ob- 
tain the  necessary  tissue  in  the  shape  of  flaps  taken  from  the  chest. 
Method  A. — Hold  the  arm  at  right  angles  to  the  chest. 
Step  I. — From  the  apex  of  the  axilla  make  a  4-inch  longitudinal  incision 
down  the  arm  immediately  behind  the  anterior  wall  of  the  axilla  along  the 
mner  and  posterior  border  of   the  coraco-brachialis  (Fig.  1226).     Elevate  the 


Fig.  1223. 


shoitldf:r. 


1041 


Fig,    1224. — (iVyeih.) 
Shoulder-joint  amputation.     Pins  and  rubber-tube  tourniquet  in  position. 


Anterior  circumfl 


Posterior  circumflex  a 


Muscular  branch 


Fig.   1225. — {Deavt 


I042  AMPUTATION    OR   DISARTICULATION. 

pectoralis  major  and  under  it  divide  the  deep  fascia  so  as  to  expose  the  coraco- 
brachialis.  Pass  the  finger  between  the  coraco-brachialis  and  the  packet  of 
axillary  vessels  and  nerves. 

Separate  the  vessels  (artery  and  vein)  from  the  nerves  and  divide  them 
(the  vessels)  between  ligatures.  Pull  the  nerve  trunks  downwards  and  divide 
them  high  up. 

Step  2. — At  right  angles  to  the  original  incision  make  a  circular  cut  down 
to  the  bone  aU  round  the  arm  at  the  level  of  the  insertion  of  the  deltoid. 
Separate  the  soft  parts  from  the  bone  up  to  its  head.     Disarticulate. 

Step  T,.- — Review  the  wound.    Trim  away  redundant  tissue.    Suture.    Dress. 

Method  B. — Spence's  operation  or  racket  method. 

Step  I. — Slightly  abduct  arm.  Rotate  humerus  outwards.  Beginning 
immediately  external   to  the  coracoid  process  make  an  incision  downwards 


Fig.  1226. 

to  the  insertion  of  the  pectoralis  major,  which  is  cut.  This  cut  divides  the 
clavicular  fibres  of  the  deltoid  and  the  pectoralis  major.  Continue  the  incision 
in  a  curve  round  the  outer  side  of  the  arm  to  the  posterior  fold  of  the  axilla. 
The  incision  penetrates  to  the  bone,  dividing  the  lower  part  of  the  deltoid, 

Step  2. — Make  a  similar  incision  round  the  inner  or  axillary  side  of  the  arm. 
but  only  divide  the  skin  and  superficial  fat.  This  inner  incision  does  not  reach 
such  a  low  level  as  the  outer  one. 

Step  3. — Separate  the  outer  flap  from  the  bone  and  joint.  Retract  the 
flap  upwards  and  backwards  together  with  the  trunk  of  the  posterior  circumflex, 
thus  exposing  the  head  and  tuberosities  of  the  humerus. 

Step  4. — Cutting  directly  on  the  tuberosities  an^  head  of  the  humerus, 
divide  the  tendinous  insertions  of  the  capsular  muscles.  By  thorough  re- 
traction of  the  outer  flap  and  by  hugging  the  bone  with  the  knife  injury  to  the 
posterior  circumflex  artery  is  avoided;  this  is  important  as,  if  punctured,  this 
artery  is  not  easy  to  pick  up  with  forceps  and  its  obliteration  endangers  the 
nutrition  of  the  deltoid  and  skin  (Treves), 

Step  5. — Let  the  assistant  who  is  holding  the  arm  so  manipulate  it  that  the 
head  of  the  humerus  is  thrust  upward  and  outward  to  project  well  above  the 


SHOULDER    JOINT. 


1043 


glenoid  cavity.  Grasp  the  head  of  the  bone  and  pull  it  outwards.  Hugging 
the  inner  side  of  the  bone,  cut  the  posterior  part  of  the  capsule.  The  arm  is 
now  connected  with  the  body  by  the  axillary  tissues  alone.  Let  the  assistant 
grasp  these  tissues  with  his  hand  so  as  to  control  the  vessels  they  contain. 
Instead  of  the  fingers  a  gastroenterostomy  clamp  may  be  used  for  this  purpose. 
Divide  the  axillary  vessels  along  the  line  marked  in  Step  2. 

Step  6. — Ligate  the  vessels.  Cut  the  axillary  nerves  short.  Close  the 
wound,  J.  Hutchinson,  Jr.,  advises  that  all  the  synovial  membrane  be  excised 
as  a  discharge  of  synovial  fluid  sometimes  delays  union. 

Method  C. — Amputation  by  Superior  and  Inferior  Flaps. — Bring  the 
patient  to  the  edge  of  the  table.     Raise  the  arm  enough  to  relax  the  deltoid. 

Step  I. — Lift  the  deltoid  with  the  left  hand.  Pass  a  long,  narrow,  strong 
knife  from  a  point  Just  below  the  coracoid 
process  under  the  deltoid  and  close  to  the 
anatomical  neck  of  the  humerus,  to  emerge 
at  a  point  a  little  beloiu  the  most  prominent 
part  of  the  acromion.  (The  transfixion 
may  be  accomplished  in  the  reverse  direc- 
tion equally  well.)  After  transfixing,  cut 
downwards  and  outwards  so  as  to  make  a 
rounded  flap  well  down  to  the  insertion  of 
the  deltoid. 

Step  2. — Reflect  the  flap.  Expose  the 
joint.  Divide  the  capsule  by  cutting  on  the 
head  of  the  bone.  Vigorously  rotate  the 
arm  outwards  and  divide  the  subscapularis 
and  biceps.  Rotate  the  arm  inwards  and 
carry  it  across  the  chest  so  as  to  expose 
and  divide  the  muscles  attached  to  the  great  tuberosity. 

Step  3. — Dislocate  the  head  of  the  bone.  Divide  the  capsule  ijehind  the 
head  of  the  humerus  (Fig.  1227).  Grasp  the  undivided  structures  firmly  in  a 
gastroenterostomy  clamp;  this  controls  the  axillary  vessels.  Slip  the  knife 
behind  the  head  of  the  bone.  If  the  clamp  has  not  been  applied  as  above, 
have  the  assistant  grasp  the  soft  parts  to  be  divided  behind  the  knife.  Cut 
along  the  shaft  of  the  humerus  and  make  an  inferior  flap  half  the  length  of  the 
superior.     The  rest  of  the  operation  is  the  same  as  in  Method  B. 

Method  D. — Furneax  Jordan's  Method. — Apply  an  elastic  constrictor 
high  up.  Divide  the  soft  parts  down  to  the  bone,  as  in  circular  amputation, 
3  to  4  inches  below  the  axilla.  Secure  the  vessels.  Make  a  longitudinal  inci- 
sion along  the  outer  and  posterior  aspect  of  the  limb  at  right  angles  to  the 
circular  cut.  Remove  the  bone.  This  method  is  capable  of  many  modifica- 
tions and  may  be  carried  out  after  arthrotomy  has  shown  that  the  limb  cannot 
be  saved.     The  same  may  be  said  of  Spence's  operation. 

In  operations  for  malignant  disease  in  the  aged  or  in  the  presence  ofpro- 


FiG.   1227. 


I044 


AMPUTATION    OR    DISARTICULATION. 


found  depression  or  shock,  Crile  blocks  the  nerve  trunks  and  operates  under 
what  Harvey  Cushing  calls  regional  anaesthesia. 

Crile's  Method  in  Shoulder  Disarticulation  (Problems  Relating  to 
Surgical  Operations,  Crile,  1901): 

Step  I. — Under  infiltration  with  i/io  per  cent,  cocaine  solution  make  an 
incision  along  the  outer  margin  of  the  sternomastoid  just  above  the  clavicle. 
Divide  the  deep  fascia. 

Step  2. — Retract  the  omo-hyoid  downwards,  the  anterior  margin  of  the 
trapezius  backwards,  the  posterior  margin  of  the  scalenus  anticus  forwards 


Fig.   1222,. —{Crile.) 


(Fig.  1228).  This  exposes  the  trunks  of  the  brachial  plexus  and  by  extending 
the  dissection  a  trifle  downwards  the  arching  subclavian  artery  is  seen.  When 
dissecting  look  out  for  small  nerve  twigs  in  the  connective  tissue  planes  or  ac- 
companying blood-vessels.     Anaesthetize  such  nerves  before  dividing  them. 

Step  3. — Inject  each  nerve  trunk  with  just  sufficient  cocaine  solution 
(1/2  per  cent.)  to  cause  a  localized  swelling.  The  injection  is  made  first  into 
the  outer  covering,  then  into  the  substance  of  the  trunk. 

This  "blocking"  causes  complete  loss  of  sensation  and  motion  in  the 
parts  supplied  by  the  brachial  plexus. 

Step  4. — Apply  Crile's  clamp  with  blades  protected  by  rubber  tubing,  to 
the  subclavian  arter}'. 


INTERSCAPULO-THORACIC   AMPUTATION.  IO45 

Step  5. — Amputate  by  one  or  other  of  the  methods  described.  Note  that 
cuts  on  the  outer  and  posterior  aspects  over  the  deltoid  should  be  made  low- 
down  to  avoid  skin  supplied  by  the  cervical  plexus. 

Interscapulo-thoracic  Amputation. — J.  William  White  finds  that  the 
mortality  after  this  operation  is  not  more  than  10  per  cent.,  probably  6  per 
cent.,  and  that  about  20  per  cent,  of  the  patients  who  survive  operation  remain 
well  after  three  years.  The  indications  for  interscapulo-thoracic  amputation 
are  (a)  extensive  injury;  (b)  maHgnant  disease  of  the  humerus  or  shoulder- 
joint;  (c)  Lund  has  done  this  operation  for  sarcoma  of  the  brachial  plexus 
otherwise  irremovable. 

Berger  ("Revue  de  Chir.,"  Oct.,  1898)  considers  that  disarticulation  at 
the  shoulder  does  not  give  sufficient  guarantee  against  recurrence  of  malignant 
neoplasms  of  the  upper  end  of  the  humerus.  When  recurrence  takes  place 
after  disarticulation,  the  disease  propagates  itself  along  the  scapulo-humeral 
muscles.  Interscapulo-thoracic  amputation  removes  en  masse,  these  routes 
of  dissemination;  it  further  so  opens  the  axilla  as  to  discover  enlarged  glands 
which  would  otherwise  escape  detection. 

The  only  reservation  Berger  makes  to  the  above  doctrine  is  the  following: 
Some  relatively  benign  tumors  of  bone  do  exist  (giant-cell  sarcomata;  chon- 
dromata;  myxomata  perhaps)  and  recovery  may  follow  a  limited  resection, 
i.  e.,  excision  of  the  tumor  itself.  To  justify  a  conservative  operation,  the 
tumor  must  be  clearly  circumscribed  and  encapsulated;  there  must  be  no  pro- 
longation either  along  the  muscles  or  into  the  shoulder-joint;  microscopical 
examination  of  a  segment  of  the  tumor,  made  at  the  time  of  operation,  must 
verify  the  diagnosis  of  the  exact  nature  of  the  neoplasm. 

Le  Conte's  Method.— Le  Conte  ("Congres  International  de  Medicine," 
1900)  gives  an  admirable  account  of  the  operation  as  performed  by  himself. 
It  is  as  follows: 

1.  The  incision  begins  over  the  sternal  end  of  the  clavicle,  is  carried  along 
that  bone  to  about  its  middle,  and  then  curved  downward  to  the  anterior  axil- 
lary fold.  The  skin  and  superficial  fascia  are  dissected  up,  exposing  well  the 
inner  two-thirds  of  the  clavicle. 

2.  The  clavicle  is  disarticulated  by  severing  its  attachments  to  the  sternum 
and  the  rhomboid  ligament;  the  clavicular  attachment  of  the  sterno-cleido- 
mastoid  muscle  is  cut  close  to  the  bone,  and  the  clavicular  portion  of  the 
pectoralis  major  is  separated  with  the  finger  from  the  costal  portion  of  the 
muscle  up  to  the  anterior  axillary  fold. 

3.  The  clavicle  is  now  pulled  upwards  and  forwards,  and  the  attachment 
of  the  subclavius  muscle  is  divided  at  the  first  rib.  The  pectoralis  minor  will 
now  be  well  exposed,  and  it  is  divided  and  the  coracoid  portion  reflected  upwards 
with  the  clavicle.  This  exposes  the  axilla  fully,  and  the  vessels  are  seen  travers- 
ing it  from  the  anterior  scalenus  muscle  down. 

4.  The  sheath  of  the  vessels  is  opened  and  the  vein  separated  from  the 
underlying  artery.     Two  ligatures  are  passed,  about  i  inch  apart,  around  the 


1046  AMPUTATION    OR   DISARTICULATION. 

artery  and  tied.  The  arm  is  then  held  up  to  empty  it  of  blood,  while  two 
ligatures  are  passed  around  the  vein,  but  these  are  not  tied  until  the  arm  is 
blanched.  This  renders  the  use  of  an  Esmarch  bandage  unnecessary.  It 
must  be  noted  that  the  cephalic  vein  has  joined  the  axillary  below  these  ligatures, 
or  else  a  separate  ligature  of  that  vessel  is  required. 

5.  The  vessels  are  now  severed,  together  with  the  brachial  plexus  of  nerves 


Fig.  1229. — (Thomas.) 

and  the  costal  portion  of  the  pectoralis  major.     This  completes  the  division 
of  the  anterior  attachments  of  the  arm. 

6.  A  posterior  incision  is  now  carried  from  some  point  on  the  anterior 
incision  (as  near  the  tumor  as  it  is  deemed  advisable  to  go)  directly  backwards 
and  downwards  to  the  inferior  angle  of  the  scapula  and  up  again  to  the  posterior 
axillary  fold.  The  skin  and  superficial  fascia  are  dissected  up  for  a  short 
distance. 


NERVE   BLOCKING.  IO47 

7.  The  trapezius  is  severed  and  the  transversalis  colli  or  posterior  scapular 
SiTtery  secured;  the  omo-hyoid  muscle  is  cut  and  the  supra-scapular  artery 
secured,  and  the  muscles  attached  to  the  inner  border  of  the  scapula  are  rapidly 
divided  close  to  the  bone.  Then,  the  serratus  magnus  and  latissimus  dorsi 
are  cut,  the  latter  at  the  posterior  axillary  fold.  The  arm  is  now  held  to  the 
body  by  the  skin  of  the  axilla  alone.     If  there  is  sufficient  flap  to  cover  the  wound, 


Fig.  1230. — (Thomas.) 

the  anterior  and  posterior  incisions  are  joined  through  the  axilla,  but  if  more 
skin  is  needed,  a  flap  may  be  raised  from  the  under  surface  of  the  arm.  The 
wound  is  then  closed  with  suitable  provision  for  drainage. 

Figures  1229  and  1230  show  how  Lynn  Thomas  uses  his  forceps-tourniquet 
in  interscapulo-thoracic  amputation. 

Crile's  Method. — Under  general  anaesthesia  make  an  incision  over  the 
clavicle  and  resect  the  inner  half  of  the  bone  so  as  to  expose  the  subclavian 


1048  AMPUTATION    OR    DISARTICULATION. 

vein  and  the  trunks  of  the  brachial  plexus.  Inject  each  nerve  trunk  with  a 
1/2  per  cent,  solution  of  cocaine  or  eucaine;  this  "blocks"  them.  Divide  the 
brachial  plexus.  Ligate  the  subclavian  artery  and  vein.  During  the  rest 
of  the  operation  (already  sufficiently  described)  "the  amount  of  shock  will  be 
limited  to  what  would  be  produced  by  making  the  incision  through  the  structures 
supplied  by  the  nerves  from  the  cervical  plexus,  which  is  almost  nil." 

Le  Conte  recommends  the  disarticulation  of  the  sternal  end  of  the  clavicle 
in  preference  to  a  resection  of  the  middle  portion  of  that  bone,  for  the  following 
reasons: 

1.  It  gives  the  widest  and  fullest  possible  exposure  of  the  vessels  and 
decreases  the  accidents  of  ligation  to  a  minimum. 

2.  It  insures  the  securing  of  the  artery  first,  before  the  vein  is  tied,  enabling 
one  to  elevate  the  arm  and  make  a  practically  bloodless  amputation. 

3.  The  disarticulation  is  simpler  and  quicker  than  resection  of  the  bone, 
and  there  is  less  danger  of  wounding  important  vess^s. 

4.  The  suprascapular  and  posterior  scapular  vessels,  the  only  other  vessels 
that  can  bleed,  are  easily  picked  up  before  being  cut. 

5.  In  malignant  growths,  where  the  outer  end  of  the  clavicle  is  involved, 
there  is  more  hope  of  a  radical  cure  if  the  entire  bone  with  its  periosteum  is 
removed. 

6.  It  removes  everything  in  one  piece,  a  more  surgical  procedure  when 
dealing  with  malignant  growths. 

Cinematic  or  Cineplastic  Amputations. — Vanghetti's  Amputation. — 
Vanghetti's  experiments  on  birds  show  that  if  a  tendon  or  muscle  is  separated 
from  its  insertion  and  some  inches  of  its  distal  end  are  mobilized  and  covered 
with  skin,  the  muscle  retains  its  power  of  voluntary  contraction.  If  the  distal 
end  of  the  tendon  (covered  with  skin)  is  formed  into  a  loop  or  into  a  knob 
(e.  g.,  by  being  tied  as  a  knot)  then  it  is  possible  to  attach  a  hook  or  a  string 
to  it  and  by  means  of  that  hook  or  string  to  convey  the  power,  provided  by  the 
muscle  contracting,  to  a  proper  artificial  limb.  These  were  remarkable  ex- 
periments to  be  made  by  a  country  practitioner  without  hospital  connections. 
Unfortunately  Vanghetti's  original  articles  are  not  accessible  to   the   writer. 

The  method  of  application  devised  by  Vanghetti  as  somewhat  as  follows: 
In  performing  an  amputation  preserve  as  great  a  length  as  possible  of  any 
healthy  tendons  or  muscles  distal  to  the  line  of  section  of  the  bone.  Form  the 
ends  of  these  tendons  (a)  into  loops  either  by  suturing  the  extremities  of  two 
tendons  together  or  by  folding  the  extremity  of  one  tendon  on  itself  and  fixing 
it  as  a  loop  by  means  of  a  suture;  (b)  into  a  knob  by  tying  the  end  of  the  tendon 
into  a  knot.  In  the  case  of  a  muscle  or  even  a  tendon,  instead  of  being  divided, 
a  portion  of  its  bony  insertion  may  be  chiselled  off  its  bed  and  left  attached 
to  the  tendon  or  muscle  as  a  knob.  Envelop  the  mobilized  tendon  or  muscle 
(including  the  loop  or  knob  at  its  end)  with  a  flap  of  skin.  If  a  loop  is  used 
perforate  the  skin  so  as  to  pass  a  smooth  hook  (as  an  ear-ring)  through  the 
loop  and  by  means  of  this  hook  and  a  proper  splint  keep  up  enough  tension 


CINEMATIC   AMPUTATION. 


1049 


on  the  tendon  to  prevent  secondary  contraction.  If  the  tendon  is  fashioned 
as  a  knob  it  is  unnecessar}'  to  perforate  the  skin,  a  padded  ring  may  be  made 
to  lie  around  the  skin-covered  tendon  proximal  to  the  knob,  and  by  means  of 
this  ring  the  necessary  tension  may  be  kept  up.  De  Francesco  ("Archiv. 
fiir  klin.  Chir.,"  Ixxxvii,  p.  571)  carried  out  Vanghetti's  ideas  in  the  case  of  a 
man  who  had  undergone  amputation  in  the  middle  of  the  forearm  five  years 
previously.  The  muscles  in  the  stump  retained  their  electric  irritability  and 
could  be  contracted  voluntarily. 

De  Francesco  made  a  longitudinal  incision  on  each  side  of  the  forearm 
and  through  them  exposed  the  radius  and  ulna  from  a  point  about  3/4  inch 
proximal  to  their  distal  ends,  upwards  for  about  2  inches 
(5  cm.)  (Fig.  1231).  He  divided  the  bones  3/4  inch  from 
their  distal  end  and  at  points  2  inches  higher,  thus  removing 
about  I  inch  of  each  bone.  \Vlien  healing  took  place,  a 
padded  ring  was  applied  around  the  stump  just  above  the 
two  fragments  of  radius  and  ulna,  and  after  a  little  practice 
the  patient  was  able  to  voluntary  flex  the  fingers  of  an  arti- 
ficial hand  by  means  of  cords  attached  to  the  padded  ring. 
The  power  was  obtained  by  the  flexors  and  extensors  pulling 
upward  the  knobby  stump  and  with  it  the  padded  ring  (Fig. 
1232  shows  De  Francesco's  patient  enjoying  himself). 

Vredene  (Roussky  Bratch.,  ref.  "  Journ.  de  Chir.,"  i.  No.  2) 
used  Vanghetti's  method  successfully  in  a  case  of  amputation 
of  the  hand  just  in  front  of  the  carpus.  The  superficial  flexor 
tendons  of  the  hand,  exposed  through  an  incision  in  the 
lower  part  of  the  forearm,  were  divided  transversely  at  the 
lower  part  of  the  wound,  and  their  proximal  stumps  sutured 
to  the  deep  flexors  (Fig.  1233). 

The  tendon  loop  can  readily  be  enveloped  in  skin  flaps, 
the  pedicles  of  which  may  be  divided  after  the  lapse  of  about  two  weeks.  In 
Vredene's  case  exercises  were  begun  after  about  one  month,  and  the  tendon 
loop  was  able  to  exert  a  pull  of  12  pounds.  An  artificial  hand  was  con- 
structed and  its  movable  thumb,  middle,  and  index  fingers  could  be  flexed  by 
means  of  the  tendon  loop  to  which  they  were  connected  by  a  metallic  hook. 
The  patient  was  able  to  seize  and  hold  various  objects. 

In  the  above  description  the  tendons  of  the  flexor  profundus  are  not  divided, 
but  probably  their  division  below  their  union  with  the  flexor  sublimis  would 
give  greater  mobility. 

Cinematic  amputations  have  lost  much  of  their  desirability  since  Carnes 
devised  his  artificial  arms,,  by  the  use  of  which  the  author  has  seen  a  man, 
who  had  lost  both  arms,  pick  coins  oflF  the  floor,  light  his  cigar  with  matches, 
shave  himself  and  carry  a  heavy  suit-case.  One  patient  whose  arm  was 
amputated  above  the  elbow  by  the  author,  drives  his  own  electric  motor  car. 


Fig.  1231. 


1 050 


AMPUTATION    OR   DISARTICULATION. 


Fig.  1232. — (De  Francesco.) 


Flexor  siiblwiis 


Skin  flap  sur- 
roundiriff  flexor 
subli/nis 

flex.  suMimis 
uniled  to 
flexor  profundus 

Distal  stumps  of 
flexor  sublimis 


Fig.  1233. 


LISFIL\NC  S   AMPUTATION. 


IO51 


AT^IPUTATIONS  AND  DISARTICULATIONS  OF  THE  LOWER 

EXTREMITY. 

Amputations  and  Disarticulations  of  the  Toes. — These  are  carried  out 
exactly  as  in  the  case  of  the  fingers.  When  the  great  toe  is  disarticulated  at  the 
metatarso-phalangeal  joint,  remember  that  the  great  size  of  the  head  of  the 
metatarsal  bone  requires  large  flaps  to  cover  it  and  that  in  the  presence  of 
articular  suppuration  the  sesamoid  bones  ought  to  be  removed. 

Konig  writes:  "When  operating  for  injury  or  disease  of  the  anterior  part 
of  the  foot  and  it  is  in  any  way  possible  to  retain  the  tarso-metatarsal  articu- 
lations, limit  operation  to  amputation  through  the  meta- 
tarsus. A  sufl&ciency  of  material  must  be  present  since 
the  stump  must  be  covered  by  a  plantar  flap  and  the  scar 
must  be  dorsal.  The  amputation  is  performed  exactly 
like  Lisfranc's  disarticulation  except  that  the  metatarsi  are 
divided.  We  have  often  remarked  that  too  great  con- 
servatism is  out  of  place  in  the  foot.  Thus  it  is  question- 
able if  it  makes  much  difference  to  the  patient  whether  the 
metatarsus  hallucis  is  amputated  or  exarticulated.  The 
removal  of  the  two  middle  metatarsi  makes  little  differ- 
ence to  the  patient,  but  transverse  amputation  is  always 
better  than  the  removal  of  three  metatarsi." 

Tarso-metatarsal  Disarticulation. — L  i  s  f  r  a  n  c '  s 
Amputation. — Step  i. — Put  the  foot  in  a  position  of 
plantar  flexion.  Note  the  base  of  the  first  and  of  the  fifth 
metatarsal  bone  (Fig.  1234).  On  the  dorsum  of  the  foot 
make  the  incision  ABC  down  to  the  bone  and  reflect 
all  the  soft  parts  so  as  to  expose  the  tarso-metatarsal 
articulations  freely. 

Step  2. — Put  the  foot  in  a  position  of  dorsal  flexion, 
foot  make  the  incision  ADC  and  reflect  all  the  soft  parts  m  one  long  plantar 
flap  until  the  articulations  are  exposed. 

Step  3. — Hold  the  foot  in  a  position  of  marked  plantar  flexion.  Retract 
both  flaps,  being  specially  careful  of  the  plantar  flap.  Carry  the  knife  (strong 
and  narrow- bladed)  round  the  base  of  the  fifth  metatarsal,  then  cut  forward 
and  inward  to  open  the  joints  of  the  three  outer  metatarsals.  Next  open  the 
joint  between  the  first  metatarsal  and  the  internal  cuneiform.  Holding  the 
knife  firmly,  insert  it  between  the  first  two  metatarsals  and  carry  it  backwards 
and  forwards  in  the  long  axis  of  the  limb  (Fig.  1235).  Do  the  same  between  the 
second  and  third  metatarsals.  Open  the  joint  between  the  second  metatarsal 
and  the  middle  cuneiform.  Complete  the  disarticulation.  Jacobson  wisely 
writes:  "The  method  by  disarticulation  may  be  a  useful  test  of  a  candidate's 
knowledge  and  skill  at  an  examination.  In  practice,  sawing  through  the 
metatarsals  just  below  their  bases  may  nearly  always  be  substituted,  as  giving 
equally  good  results  with  a  great  saxdng  of  time  and  trouble." 


Fig.  1234. 
On  the  sole  of  the 


I052 


AMPUTATION    OR   DISARTICULATION. 


Step  4. — Attend  to  hemostasis.     Close  the  wound  with  sutures.     Dress. 

The  great  objection  of  Lisfranc's  operation  is  that  the  projection  of  the 
internal  cuneiform  and  scaphoid  bones  makes  a  stump  which  is  likely  to  be 
painful. 

Hey's  Amputation. — The  author  has  no  experience  with  the  operation, 
but   Estes  recommends  it  as   much  preferable   to  Lisfranc's.     Barker  thus 


X 


Fig.  1235. — {Burghard.) 


describes  Hey's  amputation:  "Position  of  Patient:  Supine,  with  the  legs 
brought  well  over  the  end  of  the  table,  the  affected  limb  being  flexed,  and  rest- 
ing on  its  heel  on  the  edge  of  the  table.  The  surgeon  stands  facing  the  patient; 
an  assistant  steadies  the  flexed  limb,  on  the  outside  of  which  he  stands  facing 
the  operator. 

Lanimarks  for  Incision  and  Operation. — The  bases  of  the  first  and 
fifth  metatarsal  bones  are  the  guide  for  the  first  incision,  which  passes  with  a 


syme's  amputation. 


1053 


good  downward  curve  from  one  to  the  other,  across  the  dorsum  of  the  foot, 
forming  a  flap  which  should  reach  well  over  the  metatarsus  and  contain  all 
the  soft  tissues.  When  this  is  turned  up  the  operator  separates  the  meta- 
tarsus from  the  tarsus  by  focibly  bearing  upon  the  former  while  the  heel  rests 
on  the  table,  and  dividing  the  tense  ligaments,  remembering  the  deep  setting 
of  the  second  metatarsal  bone.  The  knife  is  placed  transversely  behind  the 
metatarsus  as  the  latter  is  drawn  forward  by  the  surgeon's  left  thumb,  and  is 
made  to  cut  downward  to  the  roots  of  the  toes.  The  long  plantar  flap  thus 
formed  is  now  cut  across,  either  from  side  to  side  or  by  transfixion  from  its 
centre,  first  on  one  side,  then  on  the  other,  the  knife  being  held  vertically  in 
each  case.  It  should  be  a  little  longer  on  its  inner  than  on  its  outer  side. 
Some  operators  prefer  to  fashion  the  plantar  flap  before  separating  the  bones. 
Others  again  recommend  cutting  through  the  base  of  the  second  metatarsal 


Fig.   i27,6.-~{Farahenf.) 


bone  vidth  a  bone-forceps  to  avoid  the  trouble  of  disarticulating  it;  or,  again, 
division  of  all  the  bones  straight  across  with  a  saw  just  below  their  bases. 
In  amputation  for  injury  the  latter  method  gives  excellent  results,  where  the 
treatment  is  distinctly  aseptic." 

Syme's  Amputation.— 5/e^  i. — Make  an  incision  down  to  the  bone  from 
the  tip  of  the  external  malleolus  to  a  point  1/2  inch  below  the  internal  malleolus. 
This  incision  goes  across  the  sole,  but  its  centre  is  slightly  curved  toward  the 
heel  (Fig.  1236).  Unite  the  upper  ends  of  this  incision  by  a  cut  straight  across 
the  front  of  the  ankle-joint. 

Step  2. — Bend  the  foot  downwards  so  as  to  put  much  tension  on  the  lateral 
ligaments  of  the  ankle.  Open  the  joint  freely  and  divide  the  lateral  ligaments. 
\Vhen  cutting  the  .soft  parts  on  the  inner  side  of  the  ankle  be  careful  to  cut 


I054  AMPUTATION    OR    DISARTICULATION. 

the  posterior  tibial  artery  low  down  because  of  its  importance  in  nourishing 
the  flaps. 

Step  3. — By  bending  the  foot  more  and  more,  separate  the  surfaces  of  the 
ankle-joint  and  expose  the  tendo  Achillis.  Divide  the  tendo  Achillis  close 
to  the  OS  calcis.  Dissect  the  heel  flap  from  the  os  calcis  from  above  downwards, 
leaving  the  flap  as  thick  as  possible  and  not  punctured.  In  children  the  epiphy- 
sis may  come  away  with  the  heel  flap  and  if  healthy  can  be  utilized.  Remove 
the  foot  (Fig.  1237). 


e.ca 


cp.a. 

Fig.  1237. — {Walsham.) 
f.  Fibula;  t,  tibia;  La,  tibialis  anticus;  elh,  ext.  long,  hallucis;  a.t.a,  ant.  tib.  art.;  a.t.v, 
ant.  tib.  vein;  e.c.d,  ext.  com.  dig.;  pn.l,  peroneus  longus;  pii.b,  peroneus  brevis;  f.l.Ii,  flex.  long, 
hallucis;  t.ach,  t.  achillis;  tp,  tib.  post;  Jl.d,  flex.  long,  dig;  p.t.a.  post,  tib.  art.,  dividing  into 
e.p.a.  and  i.p.a.,  external  and  internal  plantar  artery;  e.ca.  and  i.c.a,  ext.  and  int.  calcaneal 
branches  forming  blood  supply  of  thick  heel-flap. 

Step  4. — With  the  saw  remove  both  malleoli  and  with  them  a  very  thin 
slice  of  tibia.     As  an  alternative  remove  the  malleoli  alone  (Macleod). 

Step  5. — Trim  away  any  excess  of  tendons  or  other  tissue.  Attend  to 
hemostasis.     Close  the  wound. 

Roux's  Operation. — This  is  identical  with  Symes's  except  that  the  flap 
is  not  made  over  the  heel  but  on  the  inner  side  (Fig.  1238). 

Pirogoff's  Amputation. — Steps  1  and  2  as  in  Syme's  amputation. 

Step  3. — Make  strong  plantar  flexion  until  the  astragalus  is  dislocated 
forwards  and  the  upper  surface  of  the  posterior  part  of  the  os  calcis  comes  into 


AMPUTATION    OF    LEG. 


lO 


:)5 


view.  With  the  saw  divide  the  os  calcis  vertically  immediately  behind  its 
articular  surface  (Figs.   1239  and  1240). 

Step  4. — Remove  the  malleoli  and  a  thin  slice  of  the  tibia  as  in  Syme's 
operation. 

Step  5. — Divide  the  tendo  Achillis  at  its  insertion. 


Fig.   1238. — -(Stimson.) 

Step  6. — Complete  the  operation  as  in  Syme's. 

The  sawn,  surface  of  the  posterior  end  of  the  os  calcis  unites  to  the  tibia, 
giving  a  good  stump. 

Pirogoff's  operation  is  very  difficult  to  perform,  and  accidents  in  healing 
may  lead  to  distortion  of  the  stump. 


Fig.  1239.  Fig.  1240. 

{Esmarch  and  Kowalzig,)         (Esmarch  and  Kowalzig.) 


Fig.  1241. 
{Esmarch  and  Kowalzig.) 


Le  Fort's  Operation,  a  modification  of  Pirogoff's,  is  sufficiently  explained 
by  figure  1241.  The  incision  crossing  the  sole  lies  at  the  posterior  margin  of 
the  navicular  bone. 

Amputation  of  the  Leg. — The  paragraphs  devoted  to  amputating  in 
general  describe  sufficiently  the  usual  methods  of  removing  the  leg. 


1056 


AMPUTATION    OR    DISARTICULATION. 


Osteoplastic  Amputations. — Osteoplastic  amputations  are  less  serviceable 

after  trauma  than  after  disease. 

Bier. — Osteoplastic  Amputation  Leg. — Bier's  operation  may  be  carried 

out  either  on  the  basis  of  a  circular  or  a  flap  amputation.     The  circular  method 

will  be  here  described. 

Step  I. — Make  the  usual  circular  incision  through  the  skin  and  subcutaneous 
tissue,  being  specially  careful  not  to  injure  the 
periosteum.  Reflect  a  cuff  of  skin  upwards 
(Fig.  1242). 

Step  2. — With  a  knife  trace  out  a  periosteal 
flap  with  its  pedicle  above,  on  the  free  surface  of 
the  tibia.  With  a  fine  saw  or  chisel  (the  chisel  is 
liable  to  splinter  the  bone)  separate  a  shell  of 
bone  from  the  tibia  so  that  a  flap  is  formed  con- 
sisting of  periosteum  and  bone.  The  shell  of 
bone  ought  to  be  long  enough  to  cover  the  cut 
surface  of  the  tibia  and  the  fibula  (Bier's  method) 
after  the  limb  is  amputated,  or  to  cover  the  cut 
surface  of  the  tibia  alone  (Kocher).  When 
sufficient    bone   has    been    cut    away   or  shaved 


■^5 

:=z 

-J^ 

--^i 

-i'f 

^^.. 

x:g4. 

y^ 

^WU 

%| 

=  5^ 

i 

^^# 

^'- 

i^ 

i 

Fig.  1242. 


Fig.  1243. 


off  the  tibia  continue  the  separation  of  the  periosteal  flap  from  the  tibia 
upwards  to  the  line  where  the  bone  must  be  divided  (Fig.  1242).  Complete 
the  amputation. 

Step  3. — Turn  the  periosteal-bone  flap  so  as  to  cover  the  sawn  ends  of  the 
tibia  and  fibula  or  of  the  tibia  alone  with  the  shell  of  bone  (Fig.  1243).  Fix 
it  in  position  with  a  few  sutures. 

Step  4. — Attend  to  hemostasis.     Close  the  wound. 

This  operation  gives  a  very  excellent  stump. 

Bier's  method  may  be  modified  in  various  ways,  one  of  the  principal 
modifications  being  to  construct  a  flap  of  skin,  periosteum  and  a  shell  of  bone 
instead  of  periosteum  and  bone  alone. 

Figures  1244,  1245,  1246,  1247,  from  Trzebicky  and  Frommer's  article 
(Archiv.  fur  klin.  Chir.,"  Ixx,  472)  illustrate  this  method  admirably.  Note  in 
figure  1247  that  a  segment  of  bone  is  removed  at  the  base  of  the  bone  flap, 
this  is,  of  course,  to  permit  the  folding  over  the  flap.  Figure  1248  shows  the 
application  of  the  same  principle  in  amputation  of  the  thigh. 


OSTEOPLASTIC  AMPUTATION. 


1057 
describes     tliis 


Haffter's    Osteoplastic    Amputation    Leg. — Dumont 
operation  ("Deutsche  Zeitschrift  fur  Chir.,"  xcii,  497). 

Step  I. — Make  an  obliquely  oval  incision  through  the  skin.     On  the  outer 
side  of  the  limb  the  incision  is  at  a  much  lower  level  than  on  the  inner  side. 


Fig.  1244. —  {Trzebicky  and  Frommer .)  FiG.   1245. — {Trzcbicky  and  Frotnmer.) 


Fig.  1246. — {Trzebicky  and  Frommer.) 


Fig.  1247. — {Trzebicky  and  Frommer.) 


Step  2. — On  the  inner  side  retract  the  skin  upward  in  the  usual  manner  and 
cut  through  the  periosteum  of  the  tibia  (Fig.  1249,  a).  Push  the  periosteum 
upwards  for  about  1/2  inch.     Divide  the  tibia  with  a  Gigli  saw  (Fig.  1249,  A). 

Separate   the   soft   parts   from  the  tibia  downwards.     Expose  the  fibula 
near  the  outer  level  of  the  oval  skin  incision.     Divide  the  fibular  periosteum 
(Fig.  1249,  b)  and  push  it  upwards  so  as  to  form  a  cuflf.     Divide  the  fibula 
(Fig.  438,  B). 
67 


I058 


AMPUTATION    OR   DISARTICULATION. 


Fig.  1248.- — -{Trzebicky  and  From mer.) 


Fig.  1249. 


Fig.  1250. 
[Esmarch  and  Kowalzig.) 


Fig.  1251. 
(Farabeuf.) 


Fig.  1252. 

{Farabeuf.) 
The  distance  from 
the  joint  to  A  is  equal 
to  the  diameter  of  the 
leg.  The  distance  of 
P  from  the  joint  is 
one-half  the  diameter 
of  the  leg. 


AMPUTATION  AT   KNEE.  IO59 

Step  3. — Choose  a  point  on  the  fibula  near  the  level  of  the  sawed  surface 
of  the  tibia.  At  this  point  cut,  with  a  chisel,  a  wedge  out  of  the  fibula  the  base 
of  the  wedge  being  directed  towards  the  tibia  (Fig.  1249,  X). 

Step  4. — Bend  or  break  the  fibula  so  that  it  may  be  laid  over  the  sawn  sur- 
face of  the  tibia.  Vivify  the  surface  of  the  fibula  apposed  to  the  tibia.  Attend 
to  hemostasis.  Close  the  wound  with  deep  and  superficial  sutures  in  such 
a  manner  that  the  mobilized  portion  of  fibula  is  left  in  contact  with  the  end 
of  the  tibia.  Excellent  results  have  been  obtained  by  this  operation  which 
seems  simple  and  sensible. 

Disarticulation  at  the  Knee. — The  ordinary  methods  of  disarticulation 
of  the  knee  require  no  special  description.  They  are  performed  by  the 
circular  (Fig.  1250),  oval  (Fig.  1251),  or  flap  (Fig.  1252)  methods.  The 
patella  may  or  may  not  be  removed. 


AMPUTATION  BESIDE  THE  KNEE. 

Method  A. — Garden's  Intra-condyloid  Amputation. — Make  the  skin 
incision  shown  in  figures  1253  and  1254.  Reflect  the  anterior  skin  flap  upwards 
in  front  of  the  patella  and  expose  the  upper  edge  of  that  bone.  Divide  the 
quadriceps  extensor  at  its  insertion.  Divide  the  ham-strings  and  the  contents 
of  the   popliteal   space.     Clear   the   femur  immediately  above  the  articular 


Fig.  1253 — {Moullin.) 

cartilage  and  divide  the  femur  at  this  level  in  such  a  manner  as  to  give  a  horizon- 
tal surface  for  the  patient  to  rest  on.  It  must  be  noted,  however,  that  the  soft 
parts  posterior  to  the  knee  contract  after  section  while  those  anterior  do  not 
do  so — hence  a  circular  flap  becomes  an  oval  one  on  account  of  the  posterior 
contraction. 

Method  B. — Gritti's  Osteoplastic  Operation. — Make  the  same  skin 
incision  as  in  Method  A,  hit  turn  up  the  patella  in  the  anteroir  flap.  Saw  off 
the  articular  surface  of  the  patella.  (Figs.  1255  and  1256).  Complete  the  am- 
putation. Place  the  sawn  surface  of  the  patella  (in  the  anterior  flap)  against 
the  cut  surface  of  the  femur.     Close  the  wound. 

Method  C. —  Sabanejeff's  Method.— Make  an  anterior  flap  similar  to 
Carden's  but  having  its  lowest  point  below  the  patellar  tubercle.  With  saw 
or  chisel  cut  off,  in  one  piece  with  the  skin  flap,  a  portion,  of  the  anterior  superior 


io6o 


AMPUTATION   OR   DISARTICULATION. 


surface  of  the  tibia  (Figs.  1257  and  1258).     Complete  the  amputation.     In  clos- 
ing the  wound  place  the  bone  in  the  anterior  flap  in  contact  with  the  divided 
end  of  the  femur.     Both  Gritti's  and  Sabanejeff's  methods  are  valuable. 
Amputations  of  the  thigh  do  not  require  special  description. 


Fig.  1254.— (A/(>m///«.) 


Fig.   i2K,i^.~iStewart.)  Fig.   x2$6.— {Stewart.) 


Fig.  1257. — {Stewart.)  Fig.   1258. — -{Stewart.) 


AMPUTATION  OR  DISARTICULATION  AT  THE  HIP. 

Methods  of  Temporary  Hemostasis. — i.  Preliminary  ligation  of  external 
iliac  artery. 

2.  Compression  of  common  iliac  artery  through  an   abdominal   incision 
(McBurney,  "Annals  Surg.,"  1894,  ii,  181). 

3.  Preliminary  ligation  of  femoral  vessels  (a)  through  a  special  incision; 
(b)  at  an  early  stage  in  the  "anterior  racquet"  operation. 

4.  (a)  Trendelenburg's  pin. 

(b)  Varick's  modification  of  Trendelenburg's  pin. 

(c)  Thomas'  forceps. 

(d)  Wyeth's  pins. 


HEMOSTASIS. 


I061 


5.  Jordan-Lloyd's  tourniquet. 

6.  Digital  compression. 

7.  Macewens'  method  of  aortic  compression. 

8.  Momburg's  method. 

9.  Senn's  method. 

Trendelenburg's  Pin. — The  pin  or  rod  is  of  steel,  15  to  16  inches  long,  1/4 
inch  wide  and  1/12  inch  thick  in  the  centre.  The  original  pin  was  provided 
with  a  removable  lance-shaped  point  2  inches  in  length.  Wyeth's  pins  would 
answer  the  purpose.  Introduce  the  pin  i  i  /2  inches  below  the  anterior  superior 
iliac  spine,  make  it  pass  in  front  of,  and  touching  the  femur  to  emerge  at  the  pos- 
terior scroto-femoral  junction.     Remove  the  point  or  protect  it  with  a  cork. 


Fig.  1259. — {Thomas.) 


Aided  by  the  pin  it  is  easy  to  apply  a  rubber  tube  in  the  figure-8  fashion  so  as 
to  compress  all  the  soft  structures  in  front  of  the  hip,  between  the  pin  and  the 
rubber  tube.  Trendelenburg  operated  by  transfixing  about  1/2  inch  below  the 
pin,  cutting  a  long  anterior  flap,  ligating  the  vessels,  removing  the  pin,  dis- 
articulating the  joint,  and,  lastly,  making  the  posterior  flap. 

Varick  ("Bryant's  Op.  Surg.")  did  not  disarticulate  until  he  had  transfixed 
a  second  time  behind  the  neck  of  the  femur. 

Thomas'  Forceps. ^ — Lynn  Thomas  has  devised  a  long  forceps,  very  like 
a  gastrectomy  clamp,  one  blade  of  which  is  passed  through  the  tissues  exactly 
like  Trendelenburg's  pin,  the  other  blade  pressing  on  the  tissues  externally 
takes  the  place  of  the  rubber  tube.  This  forceps  did  yeoman  service  in  the  Boer 
war  and  is  a  thoroughly  practical  device  (Fig.  1259). 

Wyeth's  Pins. — Provide  two  mattress  pins  each  one  foot  long  and  3/16 


io62 


AMPUTATON    OR    DISARTICULATION. 


inch  thick.  The  point  should  be  bayonet-shaped.  Insert  one  pin  1/4  inch 
below,  and  slightly  internal  to,  the  anterior  superior  spine,  make  it  pass  some- 
what superficially  through  the  tissues  at  the  outer  side  of  the  hip  to  emerge  on  a 
level  with  the  point  of  entrance.  Insert  the  other  pin  through  the  adductor 
longus  1/2  inch  below  the  perineum,  to  emerge  i  inch  below  the  ischial  tuber- 
osity (Fig.  1260).  Protect  the  points  of  the  pins  with  corks.  Apply  a  rubber 
tube  tightly  around  the  limb  above  the  pins.  The  pins  prevent  the  rubber  tube 
from  slipping  even  after  tde  joint  is  disarticulated  and  the  limb  removed. 
The  author  has  found  this  method  very  satisfactory. 


,  ^ 


'  ,#  'i' 


Fig.   1260. — -(Jacobson.) 


Jordan  Lloyd's  Tourniquet  or  Elastic  Constrictor. — Double  a  two-yard 
piece  of  stout  rubber  bandage.  Pass  it  between  the  thighs  so  that  its  middle 
lies  between  the  ischial  tuberosity  of  the  side  to  be  operated  on  and  the  anus. 
Lay  a  common  roller  bandage  (size  for  the  thigh)  lengthwise  over  the  external 
iliac  artery.  Pull  the  ends  of  the  rubber  bandage  upwards  and  outwards,  one 
in  front  and  one  behind,  to  a  point  above  the  centre  of  the  iliac  crest  of  the  same 
side.  There  must  be  no  pulsation  in  the  femoral  and  tibial  arteries  when  the 
band  is  in  position.  The  front  part  of  the  rubber  band  runs  parallel  to,  and 
just  above  Poupart's  ligament  and  by  means  of  the  roller  bandage,  compresses 
the  external  iliac  artery.  The  posterior  part  of  the  rubber  band  crosses  the 
great  sacro-sciatic  notch  and  controls  the  branches  of  the  internal  iliac.  The 
ends  of  the  bandage  may  be  held  by  an  assistant  or  secured  as  a  figure  8,  round 
the  body.     This  method  has  not  the  safety  of  those  of  Wyeth  or  Thomas. 

Digital  compression  of  the  femoral  artery  is  unsatisfactory. 

Macewen's  Method. — Compression  of  the  Aorta. — Arrange  the  patient 
exactly  as  he  is  to  lie  during  the  operation.  Place  a  platform  or  steady  stool  by 
the  left  side  of  the  table  of  such  height  that  an  assistant  standing  on  it  can  lean 


HEMOSTASIS.  I063 

over  sidewise  and  with  his  right  elbow  fully  extended  lay  his  closed  fist  on  the 
aorta  immediately  to  the  left  of  the  umbilicus.  The  assistant  placed  as  above, 
facing  the  patient's  feet,  stands  on  his  left  foot,  his  right  foot  crossing  the  left, 
leans  on  his  right  fist  and  so  compresses  the  aorta  with  the  minimum  of  fatigue. 
The  writer  can  vouch  for  the  simplicity  and  efficiency  of  the  method;  he  can 
also  vouch  for  the  fatigue  of  the  assistant  at  the  close  of  the  operation. 

Momburg's  Method  of  Controlling  the  Circulation  in  the  Lower  Half 
of  the  Body. — ("Zentralblatt  fiir  Chir.,"  1908,  No.  23)  is  appHcable  not  merely 
to  operations  about  the  hip-joint,  but  to  interilio-abdominal  amputations  as  well. 
Apply  a  rubber  tube  (as  thick  as  a  man's  finger)  under  full  tension,  two  to  four 
times  around  the  waist  of  the  patient  between  the  iliac  crest  and  the  lowest 
ribs.  Watch  the  femoral  pulse;  as  soon  as  it  is  no  longer  palpable,  enough 
constriction  has  been  appHed.  As  soon  as  the  operation  is  completed,  apply 
an  elastic  bandage  to  both  Hmbs  from  the  feet  up  if  the  operation  has  been  on  the 
pelvis,  or  to  the  remaining  limb  if  one  has  been  amputated.  Elevate  the  limb. 
Remove  the  constrictor  from  around  the  waist.  Gradually  remove  the  elastic 
bandage  from  the  limb  so  as  to  permit  the  circulation  to  be  resumed  by  degrees 
in  the  lower  part  of  the  body  lest  too  great  a  strain  be  suddenly  put  on  the  heart. 
Bier,  Axhausen,  and  others  have  used  Momberg's  method 
with  success  and  satisfaction. 

The  methods  of  performing  amputation  or  disarticu- 
lation at  the  hip-joint  are  innumerable,  only  a  few  will  be 
described  here. 

I.  External  Racquet  Incision. — This  operation  and 
its  modifications  are  practically  identical  with 

Furneaux  Jordan's  Method. — Place  the  patient  on 
his  back  with  the  buttocks  resting  on  the  extreme  end  of 
the  table.  Let  the  assistant  hold  the  leg  and  manipulate 
the  limb  according  to  instructions.  If  desired,  provide 
for  temporary  hemostasis.  Slightly  adduct,  flex  and  rotate 
the  thigh  inwards. 

Step  I. — Make    a  longitudinal  incision  from  a  point 
about  2  inches  above  to  a  point  about  6  inches  below  the     fig.  1261. — (Bryant.) 
tip  of  the  trochanter  major.     This  incision  runs  along  the 
femur  near  the  posterior  edge  of  the  trochanter  and  penetrates  at  once  to  the 
bone  (Fig.  1261). 

Step  2. — With  a  stout  knife  divide  the  muscular  attachments  of  the  trochanter 
major,  and  expose  the  joint.  Before  dividing  the  muscular  attachments  it 
may  be  well,  in  certain  cases,  to  expose,  open,  and  explore  the  joint  so  that  the 
alternative  of  resection  may  be  adopted  instead  of  amputation,  under  proper 
circumstances. 

With  periosteal  elevator,  stout  knife  or  scissors  separate  the  soft  parts  from 
the  femur  (most  difiicult  at  the  trochanter  minor  and  the  linea  aspera)  for  the 
full  length  of  the  longitudinal  wound. 


1064  AMPUTATION    OR   DISARTICULATION. 

Step  3. — ^Method  A. — Senn's  Method. — Dislocate  the  head  of  the  femur 
and  make  it  protrude  through  the  wound.  Introduce  a  closed  forceps  through 
the  wound  and  force  it  through  the  tissues  on  the  inner  side  of  the  thigh  so  as  to 
make  a  prominence  on  the  skin.  Divide  the  skin  over  the  point  of  the  forceps 
and  grasp  in  its  blades  the  middle  of  a  length  of  rubber  tubing.  Pull  the  tubing 
through  the  wound  and  divide  the  tube  where  it  was  grasped  by  the  forceps, 
thus  leaving  two  portions  of  elastic  tubing  passing  completely  through  the  thigh. 
Tie  one  of  these  tubes  tightly  around  the  anterior,  the  other  round  the  posterior 
mass  of  tissue's.  This  insures  hemostasis  during  the  completion  of  the  amputa- 
tion. 

Method  B. — Dislocate  the  head  of  the  femur  and  make  it  protrude  through 
the  wound.  Pass  one  blade  of  a  Thomas's  clamp  (a  gastrectomy  clamp  will  do) 
through  the  wound  and  make  if  perforate  the  skin  on  the  inner  side  of  the  thigh. 
Let  the  other  blade  of  the  clamp  pass  over  the  front  of  the  thigh.  Tighten  the 
clamp.  This  insures  hemostasis  in  the  anterior  flap  where  the  principal  vessels 
lie.  If  desired  a  similar  forceps  may  be  applied  to  the  posterior  side  of  the 
thigh,  or  the  soft  parts  of  the  anterior  side  may  be  divided,  the  vessels  secured 
and  then  the  same  forceps  applied  to  the  posterior  tissues,  which  may  be  divided 
in  turn.     This  method  of  using  forceps  (Thomas)  seems  very  practical. 

Method  C. — From  the  lower  end  of  the  vertical  incision  make  a  circular 
or  oblique  incision  through  the  skin  and  subcutaneous  tissues  completely  round 
the  thigh  at  a  distance  of  6  to  8  inches  from  the  tip  of  the  trochanter.  Dissect 
the  skin  upwards  for  about  2  inches,  at  this  level  divide  the  muscles  and  remove 
the  limb.  As  soon  as  the  muscles  are  divided  the  vessels  must  be  secured. 
This  method  is  identical  with  the  two  preceding  ones  except  in  the  matter  of 
hemostasis. 

Step  4. — The  limb  having  been  removed  attend  to  final  hemostasis.  Inspect 
the  acetabulum  for  disease  and  treat  such  disease  if  found.  Close  the  wound 
after  providing  for  drainage. 

Remark. — The  racquet-shaped  incision  provides  a  wound  which  lies  as 
remote  as  possible  from  the  nates  and  genitalia. 

2.  Wyeth's  Amputation. — Introduce  Wyeth's  pins  (p.  1061).  Apply  elastic 
constrictor  above  the  pins. 

Step  I. — Make  a  circular  incision  around  the  thigh  about  2  to  2  1/2  inches 
below  the  lesser  trochanter,  dividing  the  skin  and  subcutaneous  tissues  alone. 
Reflect  the  skin  upwards  to  the  level  of  the  lesser  trochanter.  At  this  level 
divide  the  muscles  circularly  to  the  bone. 

Step  2. — Make  a  vertical  incision  over  the  line  of  the  external  surface  of  the 
femur  from  the  elastic  constrictor  to  the  circular  incision.  Ligate  all  the  prin- 
cipal vessels  in  the  wound. 

Step  3. — Separate  all  the  soft  parts  from  the  femur  upward  from  the  circular 
incision.  Disarticulate  the  hip.  To  accomplish  disarticulation  divide  the  cap- 
sular ligament,  make  a  notch  in  the  cotyloid  ligament  to  permit  air  to  enter  the 
joint,  manipulate  the  limb  to  expose  the  ligamentum  teres,  divide  this  ligament. 


DISARTICULATION  HIP. 


1065 


complete  the  dislocation  by  manipulation,  using  the  limb  as  a  lever.  Some 
surgeons  divide  the  femur  as  soon  as  they  make  the  circular  division  of  the  mus- 
cles, the  loss  of  the  limb  as  a  lever  makes  disarticulation  of  the  joint  needlessly 
difficult. 

Step  4. — Remove  the  limb.  If  any  vessels  are  visible,  ligate  them.  Remove 
the  elastic  constrictor  or  pins.  Attend  to  hemostasis.  Provide  for  drainage. 
Close  the  wound.  Apply  dressings.  Wyeth's  operation  has  given  great  satis- 
faction to  all  who  have  used  it.     It  is  very  easy  and  safe. 


Psoas 
Sartorius 

Rectus 


Vastus  ext 


Crural  n. 
Femoral  a. 
-Femoral  v. 


Fig.   1262. — (Kocher.) 

3.  Anterior  Racquet  Incision. — This  method  is  convenient  because  at 
the  very  beginning  of  the  operation  the  femoral  vessels  are  exposed — doubly 
ligated  and  divided.  The  incision  encircling  the  limb  in  an  oblique  fashion 
may  be  so  arranged  as  to  form  two  practically  equal  flaps,  one  long  external 
flap,  one  long  internal  flap,  two  unequal  lateral  flaps  or  one  long  posterior  flap. 
This  freedom  of  choice  in  obtaining  material  to  cover  the  stump  is  of  im- 
portance, as  the  site  of  disease  and  skin  involvement  may  render  it  necessary  to 
remove  much  skin  and  soft  structures.     The  anterior  racquet  method  is  entirely 


I066  AMPUTATION   OR   DISARTICULATION. 

analogous  to  the  removal  of  a  tumor  from  the  body,  in  this  case  the  limb  being 
considered  as  tumor. 

Step  I. — From  a  point  immediately  below  the  centre  of  Poupart's  ligament 
make  a  vertical  incision  downwards  for  3  to  4  inches.  Expose,  doubly  ligate, 
and  divide  the  common  femoral  artery  and  vein.  Divide  the  crural  nerve 
(Fig.  1262). 

Step  2. — At  the  lower  end  of  the  vertical  incision  make  an  obliquely  circular 
cut  all  round  the  limb,  dividing  the  skin  and  subcutaneous  tissues.  Reflect  the 
skin  upward  for  about  2  inches,  and  divide  the  muscles  at  this  level.  Any 
vessels  divided  (obturator,  superior,  and  inferior  gluteals)  must  be  caught 
in  hemostasts. 

Step  3. — Separate  from  the  bone  any  soft  structures  still  attached,  and  remove 
the  limb  by  disarticulation. 

Step  4. — Attend  to  hemostasis.  Provide  for  drainage.  Close  the  wound. 
Dress. 

The  operation  as  above  described  is  suitable  in  many  cases,  but  the  remote 
results  of  disarticulation  of  the  hip  for  sarcoma  of  the  femur  cannot  be  described 
by  any  milder  term  than  vile.  This  is  due  to  the  fact  that  the  sarcoma  early 
involves  the  soft  parts — for  instance,  the  muscles — and  of  these  principally  the 
adductors  (Quenu  et  Desmarest,  "Rev.  de  Chir.,"  1903,  No.  5).  Given  a 
patient  with  fair  vitality,  one  should  therefore  modify  Step  2  of  the  anterior 
racquet  method  so  as  to  expose  and  divide  the  muscles  at  their  pelvic  origin. 

The  author  suggests  the  following  metliod  of  disarticulation  of  the  hip  as 
being  theoretically  suitable  in  sarcoma  of  the  femur. 

Step  I. — Through  a  muscle-splitting  incision  expose  the  common  iliac 
artery  preferably  extraperitoneally.  Apply  to  the  vessel  Crile's  clamp  or  a 
temporary  ligature.  Pack  and  protect  the  wound,  if  necessary  using  a  stitch  or  a 
small  volsellum  forceps  to  temporarily  close  the  wound. 

Step  2. — Make  a  vertical  incision  below  Poupart's  ligament;  expose,  doubly 
ligate,  and  divide  the  femoral  vessels.     Divide  the  anterior  crural  nerve. 

Step  3. — Beginning  at  the  lower  end  of  the  vertical  incision  trace  out  and 
reflect  flaps  of  skin  and  subcutaneous  tissues  sufficient  to  cover  the  wound  which 
will  be  left  by  the  operation.  These  flaps  of  skin  and  subcutaneous  tissues 
must  be  reflected  up  to  the  crest  of  the  ilium,  the  rami  of  the  pubis  and  ischium, 
the  ischial  tuberosity,  etc., etc.,  so  that  the  muscles  connecting  the  femur  to  the 
trunk  are  completely  exposed,  except  of  course  those  coming  from  inside  the 
belly. 

Step  4. — Separate  the  muscles  from  the  pelvis  at  or  very  near  their  origin 
and  dissect  them  downwards  until  the  hip-joint  is  exposed  all  around.  Divide 
the  muscles  coming  to  the  femur  from  inside  the  pelvis;  these  cannot  be  excised. 

Step  5. — Disarticulate.     Remove  the  limb. 

Step  6. — The  femoral  vessels  have  already  been  ligated.  Look  out  for  and 
ligate  the  gluteal  and  sciatic  vessels  (Fig.  1263).  Pick  up  and  ligate  all  visible 
vessels.     Pack  the  huge  wound  with  gauze  wrung  out  of  very  hot  water. 


INTERILIO-ABDOMINAL  AMPUTATION. 


1067 


Step  7. — Reopen  the  abdominal  wound.  Let  a  competent  assistant  remove 
the  Crile's  clamp  and  hold  himself  ready  to  compress  the  iliac  if  necessary. 
Review  the  amputation  wound.  iVrrest  all  hemorrhage.  Provide  for  drainage. 
Close  the  wound. 

Step  8. — Close  the  abdominal  wound.     Apply  dressings. 

Interilio-Abdominal  Amputation  (Jaboulay's  Operation). — Step  i. — 
Begimiing  at  the  symphysis  of  the  pubis,  make  an  incision  parallel  to  and  be- 
low Poupart's  ligament.  Continue  the  incision  the  whole  length  of  the  crest  of 
the  ilium.  Expose  the  peritoneum  without  opening  it  and  separate  it  by  gauze 
dissection  from  the  underlying  structures  until  the  common  iliac  vessels  are 
exposed.  Doubly  ligate  and  divide  the  common  iliac  artery.  Do  the  same 
to  the  external  iliac  vein. 


Gluteus  max. 


Sup.  glut.  a. 


Sciatic  a; 


Sciatic  n. 


Glut.  med. 


Glut.  a. 

i^      Sup.  glut,  n 
Glut.  a. 

Glut.  min. 
Sm.  Sciatic'n. 
/       Int.  pud.  n. 


Fig.   1263. — (Poirier  and  Char py.) 


Step  2. — Make  a  circular  incision  through  the  skin  and  subcutaneous  tissues 
completely  round  the  thigh  at  the  junction  of  its  middle  and  upper  thirds. 
From  a  point  in  the  middle  line  of  the  anterior  surface  of  the  thigh  make  an 
incision  upwards  and  inwards  reaching  from  the  circular  incision  to  the  pubis. 
From  the  same  point  make  a  similar  incision  up  to  the  anterior  superior  spine. 
These  two  cuts  meeting  the  cut  make  in  Step  i.  surround  a  triangle  of  tissue 
which  must  be  sacrificed,  and  outline  a  very  large  posterior,  cuff-like  flap. 
Reflect  the  cuff-like  flap  of  skin  and  subcutaneous  tissue  so  as  to  expose  the 
whole  base  of  the  thigh  and  its  pelvic  connections. 

Step  3. — Retract  the  spermatic  cord  (or  round  ligament)  inwards  and  upwards. 


Io68  AMPUTATION    OR   DISARTICULATION. 

Separate  the  rectus  and  pyramidal  muscles  from  the  pubis  on  the  affected  side 
With  a  stout  knife  divide  the  symphysis.  Separate  the  corpus  cavernosum  and 
the  muscles  and  fascia  from  the  ischio-pubic  rami.  Abduct  the  thigh  forcibly 
so  as  to  make  the  symphysis  gape.  Separate  from  the  bone  the  soft  structures 
arising  from  the  inner  surface  of  the  ilium,  as  the  thigh  is  more  and  more  ab- 
ducted. If  these  structures  are  involved  remove  them  also.  Divide  the  psoas. 
Expose  and  divide  the  sacro-iliac  articulation  from  within  outwards.  Divide 
the  structures  emerging  through  the  sciatic  notches.  When  this  is  done  it  is 
easy  to  remove  the  limb  and  corresponding  portion  of  the  pelvis. 

Step  4. — After  reviewing  the  wound,  cover  it  by  the  large  cufif-iike  flap. 
Various  modifications  of  the  above  operation  have  been  attempted.  At  the 
best  it  is  a  most  formidable  procedure.  If  the  disease  is  sarcoma,  recurrence  is 
almost  sure  to  take  place  should  the  patient  survive  the  operative  ordeal. 
When  the  operation  seems  indicated  for  tuberculous  disease  of  the  hip  involving 
the  ilium,  most  surgeons  would  operate  in  two  or  more  stages,  for  instance: 
(a)  Amputate  or  disarticulate  at  the  hip-joint.  This  per  se  might  so  increase 
the  resisting  power  of  the  patient  by  removing  a  great  source  of  absorption  that 
nature  might  possibly  cure  the  patient,  (b)  At  a  later  stage  the  surgeon  may 
remove  part  or  all  the  ilium  as  may  be  indicated. 


CHAPTER  CVIII. 
FLAT-FOOT. 

Ogston's  Operation. — Apply  Esmarch's  bandage.  On  the  inner  side  of  the 
foot  make  an  oblique  incision  in  such  a  manner  that  the  middle  of  the  cut 
crosses  the  astragalo-scaphoid  articulation.  With  a  periosteal  elevator  expose 
those  portions  of  the  head  of  the  astragalus  and  the  scaphoid  which  are  con- 
tiguous to  the  joint.  With  a  chisel  remove  sufficient  of  these  bones  (especially 
of  the  astragalus)  that  when  their  cut  surfaces  are  approximated  the  sole  of  the 
foot  is  arched  in  the  normal  fashion.  Ogston  maintains  the  bones  in  apposition 
by  means  of  bone  pegs;- this  is  perhaps  unnecessary.  Close  the  wound  with- 
out drainage.  Dress.  Immobilize  with  plaster  of  Paris.  Place  limb  in  ele- 
vated position.     Remove  Esmarch's  bandage.     Treat  the  case  as  a  fracture. 

Gleich's  Operation. — Gleich  in  1893  described  his  operation  of  cuneiform 
osteotomy  of  the  os  calcis.  Brenner  modified  the  operation  in  that  he  advised  a 
mere  oblique  section  of  the  bone  in  place  of  the  removal  of  a  wedge.  It  is 
Brenner's  modification  as  performed  in  von  Eiselsberg's  clinic  that  is  here 
described.  The  results  have  been  very  good.  Riedl  reports  that  87  per  cent, 
of  Brenner's  patients  are  cured,  many  of  them  being  able  to  serve  in  the  army. 

Step  I. — Apply  an  elastic  constrictor  to  the  thigh.  Place  the  foot  and  ankle 
on  a  sand-bag  in  such  a  manner  that  the  whole  inner  (tibial)  side  of  the  foot  and 
ankle  is  imbedded  in  and  steadied  by  the  sand-bag.  One  finger's  breadth  be- 
hind the  external  malleolus  make  an  oblique  incision  down  to  and  through  the 
periosteum  of  the  os  calcis.  Brenner  prefers  to  operate  on  the  inner  side  (H. 
Riedl.  " Archiv  fur  Klin.  Chir.,"  xcii,  p.  416.) 

Step  2. — With  an  osteotome  divide  the  os  calcis  obliquely  from  above  down- 
wards and  forwards.  It  is  well  to  use  a  broadbladed  osteotome  in  order  to  avoid 
splintering  of  the  bone  and  to  leave  a  smooth  cut  surface.  As  soon  at  the  bone 
is  divided  cut  the  periosteum  on  the  inner  side  of  the  bone.  Complete  mobility 
of  the  posterior  fragment  of  bone  is  necessary;  if  it  is  not  mobile  some  undivided 
strands  of  periosteum  must  be  looked  for  and,  when  found,  cut. 

Step  3. — Push  the  fragment  of  bone  downwards,  forwards  and  a  trifle  inwards 
to  the  desired  extent.  If  valgus  is  a  feature,  then  the  lateral  dislocation  of  the 
fragment  must  be  more  pronounced.  The  downward  displacement  should  be 
about  1/2  to  3/4  inch.  If  the  operation  has  been  properly  performed  the  bone 
ought  to  tend  to  stay  in  its  new  position. 

Step  4. — Hold  the  bone  in  position.  With  a  knife  or  tenotome  puncture  the 
skin  of  the  heel  over  the  end  of  the  os  calcis.  Introduce  a  drill  through  the 
skin  puncture,  and  fix  the  fragment  of  bone  in  its  new  position  by  means  of  this 
drill.     Brenner  does  not  nail  the  bone. 

1069 


loyo 


FLAT-FOOT. 


Step  5. — Close  the  wound  without  drainage.  Apply  dressings.  Leave  the 
drill  in  situ.  Immobilize  with  plaster  of  Paris  in  a  position  of  slight  supination 
and  plantar  flexion.     Remove  the  elastic  constrictor. 

After  about  two  weeks  remove  the  drill  without  taking  off  all  the  plaster  of 
Paris.  About  three  weeks  after  operation  renew  the  plaster  of  Paris  so  that  the 
patient  can  move  about  without  risk  to  the  calcaneum.  Bony  union  is  generally 
complete  about  six  weeks  after  operation.  Figure  1264  shows  the  result  in  a 
patient  of  v.  Eiselsberg's  two  years  after  operation. 

v.  I  Nicoladoni's  Operation. — Paralysis  of  the  gastrocnemius  is  liable  to  lead 
to  talipes  cavus,  the  arching  of  the  foot  being  caused  by  the  unrestrained  action  of 
the  short  muscles  of  the  foot.     Nicoladoni  imagined  that  if,  in  severe  flat-foot, 


Fig.  1264. — (v.  Eiselsberg.) 

the  short  muscles  were  given  free  play  by  throwing  their  antagonists  out  of  action, 
their  action  woiild  tend  to  cure  the  deformity.  If  the  tendo-Achillis  is  divided- 
and  kept  temporarily  from  reuniting  the  above  conditions  will  be  fulfilled. 
The  following  is  Nicoladoni's  operation  with  a  trivial  modification  by  Hertle. 

Step  I. — Perform  subcutaneous  tenotomy  of  the  tendo-Achillis  at  the  classi- 
cal site. 

Step  2. — At  a  point  about  i  1/2  inches  higher  than  the  puncture  of  the  teno- 
tome, make  a  longitudinal  incision  about  2  inches  long  along  the  inner  side  of 
the  tendon.  Separate  the  tendon  from  its  surroundings  and  pull  its  stump  out 
of  the  wound. 

Step  3. — Fold  the  mobilized  tendon  upwards  and  tuck  its  cut  end  under  the 
deep  fascia  of  the  leg.  Fix  the  cut  end  of  the  tendon  in  position  by  one  or  more 
sutures. 

Step  4. — Close  the  skin  wound.  Dress.  Immobilize  for  ten  days.  After 
about  ten  days  remove  all  immobilizing  apparatus  and  encourage  the  patient 
to  walk.  The  more  exercise  is  taken  the  more  likely  are  the  muscles  concerned 
to  cure  the  deformity. 


FLAT-FOOT. 


IO71 


It  was  Nicoladoni's  intention  to  repair  the  tendo-Achillis  after  the  flat-foot 
was  relieved  but  neither  he  nor  Hertle  have  found  it  necessary.  Results  are  re- 
ported to  be  excellent  not  only  are  the  pains  permanently  reheved  but  an 
anatomic  correction  of  the  deformity  is  often  obtained.  The  tendo-Achillis 
reforms  after  a  time. 

Mailer's  Operation  ("  Centralblatt  f.  Chir.,"  1903,  p.  40.) — In  flat-foot, 
especially  when  muscles  are  spastic,  the  tibialis  anticus  tendon  often  stands  out 
like  a  cord  and  its  site  is  marked  on  the  skin  by  a  pigmented  line.  The  object 
of  Mailer's  operation  is  forcibly  to  correct  the  position  of  the  foot  and  to  retain 
the  new  position  by  means  of  the  anterior  tibial  tendon.  In  thirteen  cases  the 
operation  gave  satisfactory  results. 

Step  I. — Tenotomy  of  tendo  Achillis  to  permit  elevation  of  arch  of  foot. 

Step  2. — From  a  point  below  and  behind  the  internal  malleolus  midway 
between  it  and  the  sole,  make  a  curved  incision  along  the  margin  of  the  arch  of 
the  sole  to  the  base  of  the  first  metatarsal  bone. 

Step  3. — Find  and  divide  the  insertion  of  the  tibialis  anticus  at  the  anterior 
end  of  the  wound.     Isolate  the  tendon  up  to  the  ankle. 

Step  4. — Expose  the  plantar  surface  of  the  navicular  bone  and  bore  a  hole, 
the  size  of  a  lead-pencil,  through  it  from  below  upwards  and  slightly  backwards. 

Step  5.- — Pull  the  tendon  of  the  tibialis  anticus  through  this  bone  tunnel  by 
means  of  a  thread. 

Step  6. — Push  the  arch  of  the  foot  forcibly  upwards.  Pull  the  tendon  strongly 
down  and  wind  it  around  the  inner  margin  of  the  navicular  bone.  Fix  the 
tendon  to  the  bone  or  periosteum  with  wire  sutures.  Close  the  wound  without 
drainage.  Dress.  Immobilize  in  plaster  of  Paris  for  four  weeks,  after  which 
massage  and  passive  movements  are  begun.  The  "flat-foot  sole"  should  be 
used  until  there  is  complete  functional  recovery. 

According  to  Vulpius  ("Die  Sehneniiberpflanzung"),  weakness  or  paral- 
ysis of  the  tibialis  anticus  and  posticus  and  of  the  gastrocnemius  is  the  principal 
cause  of  paralytic  flat-foot  (pes  abductus  pronatus).  The  appropriate  treat- 
ment therefore  consists,  first,  in  overcorrecting  the  existing  defomity;  and, 
second,  in  preventing  recurrence  by  strengthening  the  affected  muscles,  and  if 
necessary  shortening  their  tendons.  The  after-treatment  includes  exercise  of 
the  adductors,  supinators,  and  dorsal  flexors;  and  the  use  of  an  articulated 
support  to  the  sole  until  sufl&cient  muscular  strength  is  developed.  One  example 
of  Vulpius'  method  of  treament  will  suffice: 

K.  K.,  four  years.  Paralysis  in  second  year.  Marked  equinus  and  flat-foot.  Tib.  ant. 
and  post,  completely  paralyzed.  The  other  muscles  in  good  condition.  Shortening  of  the 
Achilles  and  peroneal  tendons.  Operation:  Rectification  of  deformity.  Tenotomy  of  tendo 
Achillis.  Transplantation  of  peroneus  longus  on  to  tibialis  posticus,  of  the  extensor  hallucis 
and  a  good  portion  of  the  ext.  digitorum  on  to  the  tibialis  anticus.  Result:  After  two  months 
foot  was  in  good  position  and  all  movements  possible.  After  one  year  adduction  and  supina- 
tion could  be  carried  out  with  power. 


CHAPTER  CIX. 
TENDON  SHEATHS  AND  TENORRHAPHY. 

Operation  is  most  commonly  performed  on  the  sheaths  of  tendons  for  the 
removal  of  tuberculous  disease. 

Apply  a  tourniquet  above  the  site  of  disease.  Make  an  incision  over  the 
swelling,  following  the  course  of  the  tendon.  Split  the  sheath  of  the  tendon  wide 
open.  Retract  the  edges  of  the  sheath  wound  with  sharp  hooks  or  volsella. 
Dissect  away  all  diseased  tissues.  If  possible,  do  not  touch  the  wound  with  the 
fingers  unless  gloves  are  worn.  Rub  into  the  whole  wound  sterile  iodoform. 
Close  the  wound  by  sutures.     Apply  dressings  and  splint. 


Fig.  126  s. 


Fig.  1266. 


Fig.  1267. 


Tendon  Suture  :  Tenorrhaphy. — To  avoid  unnecessary  cutting  it  is  well 
to  use  a  round  needle,  such  as  is  used  in  intestinal  work,  but  this  is  not  of  much 
importance.  All  the  ordinary  suture  materials  are  used,  viz.,  catgut,  silk, 
hemp,  silkworm-gut,  silver  wire,  kangaroo  tendon,  etc.  If  catgut  is  chosen,  it 
ought  to  be  of  the  chromicized  variety. 

The  accompanying  figures  elucidate  the  various  methods  of  applying  sutures 
better  than  any  number  of  words  (Figs.  1265  to  1274).  Note  in  figure  1269  the 
supporting  suture,  and  in  figure  1272  the  ligatures  tied  around  the  ends  of  the 
tendon  to  prevent  the  sutures  tearing  out.  Ail  the  above  methods  of  suturing 
are  applicable  where  the  divided  ends  of  tendon  can  be  brought  into  direct 

1072 


TENDON   SUTURE. 


1073 


apposition.  Sometimes  it  is  necessary  to  suture  a  round  to  a  flat  tendon,  in 
which  case  the  flat  may  be  folded  over  the  round  and  there  fixed  by  a  few  stitches 
(Fig.  1275),  or  the  end  of  one  tendon  may  be  drawn  through  a  split  or  "buttons 
hole"  in  another  tendon  and  sutured  (Figs.  1276,  1277,  1278). 


P*^ 


Fig.  1270. 


1 


wt^:i 


mi 


Tendons  being  composed  of  parallel  bimdles  of  fibres,  it  is  easy  for  sutures  to 
cut  their  way  out  by  separating  the  fibres.  Suter  ("Arch.  f.  klin.  Chir.," 
Ixxii,  728)  describes  several  easy  and  efl5cient  means  of  avoiding  this  accident. 


Fig.  1272. 


Fig.  1273. 


Figures  1279,  1280,  1281,  1282,  and  1283,  show  how  the  sutures  are  introduced; 
the  ends  of  the  sutures  are  tied  together  at  one  side  of  the  tendon  (Fig.  1284). 
After  the  sutures  are  in  place  tie  the  two  ends  a  a^  to  the  two  ends  b  b^  (Fig. 
68 


I074 


TENDON   SHEATHS  AND   TENORRHAPHY. 


1285)  and  thus  obtain  lateral  approximation  of  the  ends  of  the  tendon.  For 
further  security  the  two  ends  of  suture  a  a^  may  be  made  to  surround  both 
segments  of  tendon,  and  the  same  may  be  done  with  the  suture  b  b^  (Fig.  1286). 
After  healing  takes  place  it  becomes  impossible  to  distinguish  between  a  union 


r« 


Fig.  1274. 


Fig.  1275. 


Fig.  1276. 


Fig.  1278. 


obtained  by  this  method  and  that  by  end-to-end  approximation.  If  end-to-end 
approximation  is  desired,  the  sutures  A  aS  b  b^  may  be  used  as  relaxation 
sutures,  as  in  figure  1290.  Often  it  is  impossible  to  bring  the  ends  into  the 
desired  apposition,  owing  to  shrinkage,  loss  of  substance,  or  the  exigencies  of 


TENDON    SUTURE. 


1075 


transplantation,  and  various  means  of  tendon  lengthening  must  be  used. 
Figures  1288,  1289,  1290  and  1291  show  the  best-known  methods.  Occa- 
sionally the  above  means  are  inapplicable,  and  in  order  to  obtain  union  between 


Fig. 


1279. 


Fig.  1280. 


the  separated  ends  of  tendon  it  is  necessary  to  fill  the  gap  with  some  suture 
material  or  a  graft.  Figures  1268  and  1269  show  how  such  sutures  may  be 
applied. 


Fig.  1281. 


Fig.  1282. 


Hunkin  devised  the  following  useful  stitch: 

Put  the  two  fore  ends  of  a  double  silk  or  hemp  suture  through  the  eye  of  a 
needle.     Introduce  the  needle  into  the  cut  surface  of  one  tendon  (X)  and  make 


A« 


Fig.   1284. 


Fig.  128:;. 


m^ 


Fig.  1286. 


.8' 


Fig.  1287. 


it  follow  the  course  shown  in  Fig.  1292.     WTien  the  needle  at  last  emerges  (Y)  tie 
the  ends  of  the  suture  Y  to  the  loop  X  by  means  of  a  half-hitch. 

A  number  of  strands  of  catgut  or  catgut  and  silk  together  may  be  formed  into 


1076 


TENDON  SHEATHS  AND  TENORRHAPHY. 


a  small  cable  the  ends  of  which  may  he  sutured  to  the  divided  end  of  the  tendon. 
Whatever  material  is  used  to  fill  the  gap,  it  merely  acts  as  a  guide  or  scaffold  along 
which  nature  may  deposit  new  tendon  tissue  or  a  substitute  therefor.  Vulpius  finds 
that  even  after  aseptic  healing  silk  sutures  are  ultimately  thrown  off,  without  ill 


If 


Fig.  128 


Fig.  1 29 1. 


Fig.  1292. 


Fig.  1293. 


result,  in  15  to  20  per  cent,  of  all  cases  when  used  as  ordinary  tendon  sutures. 
When  used  as  grafts,  more  damage  must  follow.  Probably  as  a  graft,  chromi- 
cized  catgut  or  prepared  tendon  is  preferable  to  silk.  A  combination  of  silk  and 
catgut  is  well  recommended.     If  two  neighboring  tendons  are  in  part  destroyed 


TENDON    SUTURE. 


1077 


by  the  same  accident,  a  portion  of  the  less  important  one  may  be  used  to  replace 
the  defect  in  the  more  important  (Fig.  1293).  When,  as  a  result  of  an  incised 
wound,  e.g.,  of  the  dorsum  of  the  foot,  a  tendon  is  divided,  the  proximal  end 
is  immediately  retracted  into  its  sheath.  To  find  the  retracted  portion  pass 
forceps  up  the  sheath,  seize  the  tendon,  and  pull  it  down.  Very  commonly 
this  procedure  is  futile,  and  we  are  compelled  to  split  open  the  sheath  for  a 
greater  or  less  distance  upwards.    The  retracted  tendon  may  be  forced  downwards 


-Perioiteum. 


'  "^/f:</;f,z','M''-iy\. 


Cutter  in  Bone 

Fig.  1294. 


by  methodically  pressing  the  muscular  belly  downwards  or  by  applying  an  elastic 
bandage  tightly  around  the  limb  from  the  origin  of  the  muscle  at  fault  downwards. 
If  after  thorough  and  extensive  search  the  upper  end  of  the  tendon  cannot  be 
found,  the  distal  end  ought  to  be  united  to  a  neighboring  tendon  by  the  methods 
shown  in  figures  1276,  1277,  and  1278.  The  approximated  surfaces  of  tendon 
must,  of  course,  be  suitably  freshened  before  the  sutures  are  applied. 

Sometimes  the  proximal  end  of  the  tendon  is  accessible  and  the  distal  lost 


Fig.  1295. 


Pig.  1296. 


or  destroyed.  Several  methods  of  treatment  are  applicable:  (a)  The  end  of 
the  tendon  may  be  united  to  the  side  of  a  neighboring  tendon.  (See  "Trans- 
plantation of  Tendons.")  {h)  The  end  of  the  tendon  may  be  fixed  to  the  peri- 
osteum or  to  the  bone  itself  at  a  point  as  near  as  possible  to  its  normal  insertion, 
(c)  The  end  of  the  tendon  may  be  united  to  the  bone  at  its  normal  point  of  in- 
sertion by  the  intermediation  of  a  catgut  or  silk  graft. 


1078 


TENDON   SHEATHS  AND   TENORRHAPHY. 


Implantation  of  tendon  to  periosteum  or  bone  may  be  affected  as  follows: 

Method  I  (Lange) . — With  knife  and  periosteal  elevator  raise  a  flap  of  peri- 
osteum, 1/2  to  3/4  inch  in  length,  at  the  site  chosen  for  the  tendon  insertion. 
Suture  the  end  of  the  tendon  to  the  periosteal  flap.  When  the  tendon  is  not 
long  enough  to  reach  the  point  of  insertion,  Lange  makes  use  of  a  double  suture 
of  strong  silk  as  a  graft. 

Method  2  (Wolff). — Divide  the  periosteum  at  the  site  selected.  Reflect  the 
periosteum  laterally.  With  a  chisel,  cut  a  gutter  or  groove  in  the  exposed  bone. 
Place  the  tendon  in  the  bone  gutter.  Replace  the  periosteal  flaps  over  the  im- 
planted tendon  and  suture  them  together  and  to  the  tendon  (Fig.  1294). 

When  tendon  suturing  is  done  as  a  secondary  operation,  the  ends  of  the 
tendon  will  be  found  adherent  to  a  mass  of  scar  tissue  lying  between  them,  and 
which  is  firmly  adherent  to  surrounding  structures,  especially  to  the  skin. 


Fig.  1297. 

Before  the  vivified  ends  of  the  tendon  are  united,  this  mass  of  firm,  hard  tissue 
must  be  thoroughly  excised  and  adhesions  which  prevent  approximation  and 
gliding  of  the  tendons  must  be  broken  down. 

Where  it  seemed  impossible  to  obtain  a  satisfactory  result  by  excising  the  scar 
tissue  in  a  case  in  which  the  distal  portion  of  the  flexor  of  the  index  finger  was 
adherent  to  the  cicatrix,  Chassaignac  sought  for,  found,  and  united  the  proximal 
portion  of  the  tendon  to  the  scar  close  to  the  distal  portion (tendo-cutaneous 
suture). 

After-treatment. — The  wound  having  been  closed,  if  possible  without 
drainage,  abundant  dressings  are  applied,  and  the  parts  fixed  by  splints  or  plaster 
of  Paris  in  such  a  position  that  tension  on  the  sutures  is  relaxed.  No  attempts 
at  motion  should  be  made  before  the  lapse  of  two  weeks,  in  the  case  of  the  smaller 
tendons;  for  the  larger  tendons  or  in  cases  where  grafts  (of  catgut,  silk,  etc.) 
have  been  employed,  a  longer  period  of  rest  is  proper.  After  this  passive  and 
then  active  motion  must  be  begun,  aided  by  massage  and  electrical  stimulation. 
Owing  to  the  occurence  of  atrophy  from  disuse  the  after-treatment  will  be  more 


TRANSPLANTATION. 


1079 


prolonged  where  the  tenorrhaphy  was  secondary  than  where  it  was  performed 
at  the  time  of  the  original  injury. 

Approximation  of  Severed  Ends  of  Tendon  by  Means  of  Transplanting 
its  Osseous  Insertion  (Bergmann,  Poncet). — It  may  be  impossible,  by 
ordinary  means,  to  approximate  the  fragments  in  transverse  fracture  of  the 
patella  in  rupture  of  the  ligamentum  patellae  or  quadriceps  tendon,  but  the 
following  operation  may  suffice  to  permit  it: 


W 


Fig.  1299. 

Step  I. — Expose  the  parts  by  means  of  a  vertical  or  crucial  incision  (Figs. 
1295,  1296). 

Step  2. — With  a  chisel  separate  the  tibial  tubercle,  and  with  it  the  ligamentum 
patella,  from  the  tibia. 

Step  3. — Divide  any  adhesions  which  prevent  approximation. 

Step  4. — Unite  the  fragments  of  bone  or  tendon  by  strong  sutures. 

Step  5. — The  fragments  of  bone  or  tendon  having  been  united,  the  separated 


Fig.  I ^00. 


Fig.  1301. 


tibial  tuberosity  attached  to  the  ligamentum  patellae  has  slipped  upwards  and 
assumed  a  new  position  on  the  surface  of  the  tibia.  Fix  the  tibial  tuberosity 
in  its  new  position  by  means  of  a  buried  ivory  peg  or  by  a  steel  nail  which  is 
left  protruding  through  the  skin  wound,  to  be  removed  after  union  has  been 
secured. 

Step  6. — Suture  the  fascia  and  skin-wounds.     Apply  dressings.     Immobil- 
ize with  splints  or  plaster  of  Paris  in  extended  position  and  elevate  the  limb. 


io8o 


TENDON   SHEATHS  AND   TENORRHAPHY. 


A  similar  operation  may  be  used  in  cases  where  there  is  much  loss  of  sub- 
stance in  the  tendo  Achillis  or  in  the  tendon  of  the  triceps  brachialis.  Figures 
1297  and  1298  are  self-explanatory. 

For  the  correction  of  deformity,  tendons  which  have  never  been  divided 
often  require  to  be  lengthened.  Tenotomy  is  the  most  common  means  of 
securing  the  necessary  elongation.  (See  "Tenotomy.")  Poncet's  method 
of  making  shallow  lateral  incisions  (Fig.  1291)  may  be  of  service  under  such 
circumstances.     Anderson's  method  of  tendon  lengthening  by  splitting,  sliding, 


Fig.  1302. 

and  suturing  is  shown  in  figure   1299.     The  Hibbs-Sporon  method  can  be 
readily  grasped   by  glancing  at  figure    1300. 

Tendon  Shortening. — After  the  correction  of  deformity  certain  tendons 
may  be  too  long  for  the  proper  transmission  of  power,  or  the  exigencies  of 
transplantation  may  require  that  they  be  shortened.  Figures  1301  and  1302 
show  a  simple  reduplication  of  the  tendon.  In  figure  1303  the  tendon  is  split 
longitudinally  and  the  longitudinal  converted  into  a  transverse  wound.  In 
figure  1304  the  whole  thickness  of  the  tendon  has  been  cut  away  with  the 
exception  of  a  thin  slip  at  the  side,  which  aids  in  the  subsequent  healing 


W 


r\ 


1 


Fig.  1303. 


Fig.  1304. 


Fig.  1305. 


In  figure  1305  a  "draw"  stitch  when  pulled  tight  throws  the  tendon  into  folds 
and  so  shortens  it.  Figures  1327,  1328,  1229,  1330,  show  in  detail  how  much 
a  tendon  as  the  Achilles  may  be  shortened.  Other  methods  of  tendon 
shortening  will  be  incidentally  described  in  the  paragraphs  devoted  to 
transplantation. 

Displacement  of  Peroneus  Longus  Tendon. — Make  an  incision  about 
2  inches  in  length,  obliquely  from  above  downwards  and  forwards,  over  the 
outer  surface  of  the  external  malleolus  (Fig.  1306).  Do  not  cut  deeper  than 
the  subcutaneous  tissue.  Expose  the  external  annular  ligament,  which  is 
torn  when  the  peroneus  tendon  is  luxated.     If  the  fragments  of  the  ligament 


TRANSPLANTATION.  IO81 

can  be  brought  into  apposition  over  the  tendon,  suture  them  in  their  normal 
position.  If  this  cannot  be  done,  expose  a  larger  surface  of  the  external 
malleolus  and  from  it  raise  a  flap  of  periosteum  with  its  base  downwards. 
Turn  this  flap  downwards  and  suture  its  free  extremity  to  the  remnants  of  the 
annular  ligament  or  to  the  periosteum  of  the  os  calcis.  Another  method 
consists  in  making  the  periosteal  flap  at  a  slightly  higher  level — turning  it 
back  over  the  peroneal  tendons  and  there  suturing  it  to  the  deep  fascia  (Fig. 
1307)  (Walsham).  Close  the  skin-wound  without  drainage.  Dress.  Immobil- 
ize for  two  weeks  and  then  begin  passive  motion. 


Fig.  1306.  Fig.  1307. 

TENDON  TRANSFERENCE  OR  TRANSPLANTATION. 

Objects. — The  objects  of  tendon  transference  are: 

"(a)  To  fortify  a  weakened  group  of  muscles. 

"  (b)  To  supplant  a  completely  paralyzed  muscle  or  group  of  muscles. 

"(c)  To  obstruct,  balance  or  oppose  an  overacting  spastic  group. 

"(d)  To  deviate  tendon  action  when  perverted — as  in  transference  of  the 
tendo  Achillis  to  the  outer  side  of  the  os  calcis  in  congenital  club-foot  to 
prevent  inversion  of  the  ankle. 

"(e)  As  a  help  in  partial  arthrodesis"  (Jones). 

Principles. — H.  O.  Thomas  has  pointed  out  that  a  muscle  may  fail  to 
act  and  may  simulate  paralysis  because  it  has  been  overstretched  while  weak. 
This  is  well  seen  in  wrist  drop.  Here  the  weakened  extensors  may  have  re- 
covered from  the  original  disease,  but  the  stronger  flexors  have  so  stretched 
and  dominated  them  that  they  no  longer  act,  while  the  dominant  flexors  have 
assumed  a  condition  of  contracture  from  long-continued  want  of  opposition. 
If  such  a  hand  is  gradually  brought  into  a  position  of  overextension  and  kept 
in  that  position  for  many  months  continuously,  recovery  may  be  expected. 
The  recovery  is  due  to  shortening  of  the  weakened  tendons  (the  muscles  of 
which  ought  of  course  to  be  treated  by  massage,  etc.)  and  to  elongation  of  the 
contracted  (flexor)  tendons  (Tubby  and  Jones). 

This  recognition  of  simulated  paralysis  is  of  very  great  importance  when 
one  is  deciding  on  operation.  Frequently  brilliant  immediate  results  have 
been  obtained  by  tendon  transference,  but  later  there  has  been  relapse.  This 
is  commonly  due  to  neglect  of  the  Thomas  principle  referred  to  in  the  preceding 


I082  TENDON   SHEATHS  AND    TENORRHAPHY. 

paragraph.  After  being  transferred  or  transplanted,  a  tendon  is  naturally 
weak  and  the  point  where  it  is  united  to  its  new  insertion  consists  of  weak- 
scar  tissue.  If  after  the  wound  has  healed  we  permit  undue  strain  (exerted 
by  gravity  or  by  opposing  muscles)  to  be  inflicted  on  the  transferred  tendon 
it  cannot  avoid  being  stretched  and  becoming  useless.  The  transferred  tendon 
ought  to  be  treated  on  the  same  principles  as  recommended  in  wrist  drop 
and  the  treatment  should  be  kept  up  until  "the  patient  is  able  by  a  voluntary 
effort  to  make  it  forcibly  act  and  it  can  successfully  withstand  the  action  of 
gravity"  (Jones).  Some  of  the  methods  of  carrying  out  these  principles  will 
be  discussed  later. 

Tendon  Transplantation. — When  there  is  a  loss  of  muscular  function, 
incapable  of  spontaneous  recovery  or  of  relief  by  simpler  means,  tendon  trans- 
plantation may  be  used.  Loss  of  muscular  function  may  be  due  to  paralysis 
or  paresis  of  a  single  muscle  or  of  a  group  of  muscles,  or  to  an  excess  of  power 
in  one  muscle  or  group  of  muscles,  i.  e.,  there  is  a  loss  of  balance  between 
the  muscles  acting  on  a  joint.  Balance  may  be  restored  by  transplanting 
power  from  the  strong  to  the  weak.  In  order  that  transplantation  may  be  of  use 
it  is  essential  that  the  loss  of  function  is  limited  in  extent  and  that  suflSciently 
powerful  muscles  are  within  convenient  distance  of  the  weakened  ones,  e.  g., 
no  benefit  could  accrue  from  tendon  transplantation  in  the  case  of  a  so-called 
"flail-joint;"  the  loss  of  function  is  too  wide-spread  and  there  are  probably 
no  neighboring  muscles  in  proper  position  to  lend  power.  Where  there  has 
been  loss  of  tendon  from  accident  or  disease,  and  union,  whether  direct,  by 
implantation,  or  by  tendon  lengthening,  is  impossible,  then  transplantation 
may  restore  function.  Frequently  paralysis  following  acute  poliomyelitis 
is  circumscribed,  so  that  healthy  muscles  are  found  alongside  paralyzed  ones; 
in  such  cases  transplantation  may  be  valuable.  Before  operating,  however, 
we  must  be  very  sure  that  spontaneous  recovery  is  impossible.  Never  operate 
until  six  or  nine  months  have  elapsed  since  the  paralysis  appeared.  Trans- 
plantation is  of  use  not  only  in  restoring  function,  but  in  obviating  deformity. 

The  most  common  forms  of  partial  paralysis  requiring  operation  are  those 
about  the  ankle  evidenced  by  the  presence  of  talipes  calcaneus,  paralytic 
varus  and  equino-varus,  and  flat-foot.  In  spastic  paralysis  the  want  of  muscu- 
lar balance  may  be  due  to  increased  power  in  one  set  of  muscles,  with  or  with- 
out diminished  power  in  the  opposing  muscles.  Inflammatory  arthritis  may 
cause  contractures  remediable  by  transplantation. 

A  well-defined  plan  of  procedure  must  be  worked  out  in  each  case  before 
operation  is  begun.  We  must  know  exactly  which  muscles  are  paralyzed 
completely  or  partially,  and  what  power  is  available  to  aid  them.  In  the  case 
of  adults  we  study  the  possible  voluntary  movements.  Movements  in  weakened 
parts  may  often  be  demonstrated  only  when  the  corresponding  muscles  in 
the  opposite  limb  are  set  in  motion.  Children  we  watch  at  play  and  stimulate 
certain  muscles  to  act  by  tickling,  etc.  When  contractures  are  present,  they 
may  hinder  certain  motions  and  may  have  caused  atrophy  in  certain  muscles 


REMARKS.  1083 

from  disuse.  Electrical  tests,  according  to  Vulpius,  are  of  comparatively 
little  value.  Weak  currents  do  not  stimulate  sufficiently;  stronger  ones  excite 
neighboring  or  even  antagonistic  muscles.  The  application  of  the  electricity 
frightens  children  and  does  not  help  in  distinguishing  between  paralysis  and 
the  atrophy  from  disuse. 

When  deformity  exists,  it  ought  to  be  corrected  before  the  required  tendon 
transplantation  is  attempted,  e.  g.,  in  paralytic  club-foot  with  paralysis  of  the 
extensor  digitorum;  if  we  transplant  part  of  the  tibialis  anticus  tendon  on  to 
the  tendon  of  the  paralyzed  muscle  and  then  correct  the  deformity,  the  tendon 
is  made  loose  and  cannot  transmit  power  to  the  foot.  If,  however,  we  first 
correct  the  deformity  and  then  make  the  transplantation,  the  tendon  will  have 
the  proper  tension  for  the  transmission  of  power.  If  the  operation  for  the 
correction  of  deformity  is  severe,  transplantation  should  not  be  attempted 
until  the  parts  have  completely  recovered  from  the  operative  trauma.  If 
contracted  tendons  hinder  complete  correction  of  deformity,  Vulpius  defers 
the  necessary  tenotomy  until  he  is  ready  to  transplant,  when  he  combines  ten- 
otomy and  tendon  splitting. 

Lorenz  ("  Centralblatt  fiir  Chir.,"  1905,  No.  49)  considers  that  the  opera- 
tion has  been  overdone,  especially  in  cases  of  paralytic  flexion  of  the  knee. 
In  such  cases  it  is  easy  to  produce  hyperextension  of  the  knee  (genu  recurva- 
tum).  For  him  the  biceps,  semimembranosus  and  semitendinosus  constitute 
a  "noli  me  tangere."  At  most,  the  gracilis,  semitendinosus,  sartorius  and 
tensor  vaginae  femoris  may  be  used  to  help  the  quadriceps,  but  this  amount 
of  help  is  insufficient. 

General  Remarks  on  Method  of  Operating. — Incisions  to  expose  the 
tendons  should  be  longitudinal  and  so  placed  that  they  may  be  slid  over  all 
the  parts  it  is  necessary  to  expose.  An  incision  ought  not  to  be  made  directly 
over  a  tendon;  it  should  be  to  one  side  of  it.  Flaps  and  V-shaped  incisions 
lead  to  extensive  skin  dissection  and  favor  the  formation  of  adhesions. 

If  the  donating  tendon  is  remote  from  the  receiving  tendon,  a  second 
incision  will  be  necessary,  and  the  tendon  is  carried  from  the  one  opening  to 
the  other  through  a  tunnel  bored  with  a  forceps.  Numerous  incisions  may  be 
made  into  both  the  donating  and  the  receiving  muscle.  These  incisions  let 
us  know  the  actual  condition  of  the  muscles.  Next  to  a  dark-red  healthy 
muscle  we  may  find  a  yellowish- white  muscle  completely  paralyzed  and  scarcely 
distinguishable  from  the  surrounding  fat.  Another  muscle  may  show  varying 
shades  of  rose  color  (atrophy  from  disuse);  such  a  muscle  may  recover.  In 
still  another  muscle  we  may  find  all  three  conditions — health,  paralysis,  atrophy 
in  streaks. 

In  exposing  the  donating  tendon  a  very  long  incision  may  be  required, 
especially  if  it  seems  necessary  to  form  two  muscles  out  of  one.  Under  such 
circumstances  not  only  is  a  slip  split  off  the  donating  tendon,  but  the  tendon 
split  or  incision  is  carried  well  up  into  the  muscle  belly.  In  continuing  the 
"split"  up  into  the  muscle  do  so  by  blunt  chssection,  and  see  that  the  portion 


1084 


TENDON   SHEATHS  AND   TENORRHAPHY. 


of  muscle  left  attached  to  each  segment  of  tendon  normally  belongs  to  that 
segment.  This  renders  possible  the  formation  of  two  physiologically  distinct 
muscles  out  of  one  (Figs.  1308  and  1309).  The  donating  tendon  must  be 
conducted  by  as  straight  a  route  as  possible  to  the  receiving  one.  To  succeed 
in  this,  e.  g.,  when  a  flexor  of  the  leg  is  to  donate  power  to  an  extensor  or  vice 
versa,  it  may  be  necessary  and  proper  to  conduct  it  through  a  tunnel  bored 
in  the  interosseous  membrane. 

A  tendon  receives  nourishment  from  its  muscle,  its  bone  insertion,  and 
its  sheath,  hence  R.  Jones,  whenever  possible,  transplants  the  tendon  sheath 
along  with  the  tendon. 

When  exposing  tendons  through  a  long  cutaneous  incision  it  is  not  necessary 
to  divide  the  fascia  throughout  the  whole  length  of  the  wound;  the  fascial 


Fig.  1308. 


Fig.  1309. 


cut  may  be  interrupted  in  places  and  thus  union  is  rendered  easier  and  more 
exact.  The  fascia  should  never  be  divided  near  its  insertion  into  bone,  other- 
wise union  will  be  difficult. 

Methods  of  Uniting  Transplanted  Tendons. — Most  of  what  has  been 
written  as  to  the  union  of  divided  tendons  is  applicable  here.  Figures  13 10 
to  1322  illustrate  sufficiendy  the  usual  methods  of  transplantation.  In  the 
figures  the  non-paralyzed  muscle  and  tendon  (the  donor)  are  uniformly  left 
imshaded;  the  paralyzed  muscle  and  tendon  (the  receiver)  are  shaded.  Before 
applying  sutures  always  vivify  the  surfaces  to  be  united  and  always  pull  up 
any  "slack"  there  may  be  in  the  receiving  tendon  so  that  sufficient  tendon 
tenseness  is  secured  to  permit  of  transference  or  application  of  muscle  power 
to  the  point  of  tendon  insertion.  A  lax  tendon  between  muscle  and  point  of 
insertion  is  useless. 

In  Figure  13 12  the  tendons  both  of  the  donor  and  of  the  receiver  are  com- 
pletely divided  and  the  peripheral  portion  of  the  donor  is  discarded,  i.  e., 
none  of  the  normal  function  of  the  donor  is  retained.  This  procedure  is 
justifiable  only  when  the  donor  is  an  entirely  unimportant  muscle  or  if,  under 
the  circumstances  for  which  operation  is  undertaken,  its  normal  action  is 
objectionable.    Functionally    negligible    muscles    are    rare,    and    unexpected 


TRANSPLANTATION. 


1085 


evils  are  liable  to  follow  when  even  unimportant  muscles  are  entirely  cut  off 
from  their  normal  insertion.  To  obviate  part  of  this,  many  devices  have  been 
suggested,  and  most  of  them  will  be  easily  understood  after  a  glance  at  the 
figures. 

Robert  Jones  believes  that  the  union  between  the  two  tendons  should  be  as 


Fig.  1310. 


Fig.  13 II. 


Fig.  1312. 


near  the  insertion  of  the  receiving  (paralyzed)  tendon  as  possible  to  avoid 
dangers  from  subsequent  stretching  of  that  structure.  He  prefers,  if  possible, 
to  implant  the  end  of  the  "donor"  into  the  periosteum  in  a  suitable  place 
rather  than  into  the  tendon  of  the  paralyzed  muscle. 


Fig.  1313. 


Fig.  13 14. 


Lange  in  his  transplantations  makes  free  use  of  artificial  tendons  of  silk 
(see  p.  1322), 

Indirect  tendon  transplantation  may  be  necessary  when  the  donor  is  not 
long  enough  and  where  the  ordinary  methods  of  implantation  seem  inadvisable. 
Mainzer  (quoted  by  Vulpius)  used  the  following  plan  in  a  case  of  paralysis 


io86 


TENDON    SHEATHS  AND    TENORRHAPHY. 


of  the  extensors  of  the  toe:  Form  a  slip  from  the  tendo  Achillis  (Figs.  1323 
and  1324);  suture  the  end  of  this  slip  to  an  appropriate  point  on  the  peroneus 
brevis  tendon.  Divide  the  tendon  of  the  peroneus  brevis  at  such  a  place  that 
a  suflSciency  of  the  tendon  is  left  below  the  point  of  suture  with  the  tendo 


Fig.  13 15. 


Fig.  1316. 


Fig.  1317. 


Achillis  to  reach  from  that  point  to  the  extensors  which  require  strengthening. 
Pull  this  chosen  portion  of  tendon  centralwards  out  of  its  sheath  and  sew 
its  end  to  the  extensors  (Fig.  1324,  6). 

Closure    of   Wound. — Suture   the    wounded    tendon   sheaths   -with   very 


Fig.  13 19. 


Fig.  1320. 


tine   catgut.     Carefully  suture   the  deep  fascia  with   buried   sutures.     Close 
the   skin-wound.     Apply  abundant   dressings  and  a  stiff  bandage. 

Several  methods  (apart  from  splints  and  apparatus)  are  available  by  means 
of  which  the  transferred  tendon  may  be  protected  from  overstretching  until 
such   time   as   it   gains   strength.     Hofifa   exposed   the   completely   paralyzed 


TRANSPLANTATION. 


1087 


tendons  which  were  supplanted  by  the  operation  and  shortened  them  so  that 
they  could  act  as  cords,  keeping  the  limb  in  a  position  of  overcorrection.  Divi- 
sion or  lengthening  of  the  active  opposing  tendons  which  stretch  the  transferred 
tendon  is  harmless  and  useful.     Robert  Jones,  in  addition  to  the  above  methods, 


Fig.  i;2i. 


Fig.   i?2; 


makes  use  of  his  "skin-flap  removal"  to  secure  uninterrupted  continuity  of 
the  overcorrection. 

After-treatment. — Keep  immobilized  for  six  weeks  in  simple  cases, 
for  eight  weeks  in  cases  where  there  has  been  much  deformity,  especially  bony 
deformity,  corrected.     The  period  of  rest  is  shortened  if  there  is  cause  to  fear 


Fig.  1323.  Fig.  1324. 

I.  Tendo    Achillis.     2.  Peroneus    longus.     3.  Peroneus    brevis.     4.  Extensor    tendons 
Slip  from  tendo  Achillis.     6.  Tendon  of  peroneus  brevis  used  as  a  graft. 


adhesions,  e.  g.,  if  the  tendon  has  been  left  outside  the  fascia  or  traverses  an 
interosseous  space.  For  a  period  of  four  weeks  the  patient  ought  to  remain 
in  bed  to  avoid  any  chance  of  injury  to  the  lines  of  suture.  After  union  is 
complete  applications  of  moist  and  dry  heat  stimulate  the  circulation.     Elec- 


I088  TENDON   SHEATHS  AND    TENORRHAPHY. 

trical  stimulation  is  advantageous.  Passive  motion  and,  as  soon  as  possible, 
gymnastic  exercises  are  necessary.  When  the  patient  begins  walking  some 
simple  form  of  supporting  apparatus  or  boot  will  be  necessary  for  a  longer  or 
shorter  time. 

Examples  of  Tendon  Transplantation. 

I.  Talipes  equinus — due  to  infantile  palsy.  The  tibialis  anticus  and  the 
extensor  communis  digitorum  are  alone  affected.  Power  from  the  extensor 
proprius  hallucis  and  from  the  peronei  muscles  may  be  transferred  to  the 
tendon  of  the  paralyzed  muscles.  In  all  the  operations  for  equinus  it  is  pre- 
sumed that  any  shortening  of  the  tendo  Achillis  which  obstructs  overcorrection 
has  been  overcome  by  tenotomy  or  by  tendon  lengthening. 

(A)  Transplantation  of  a  "slip"  from  the  tendon  of  the  peroneus  brevis 
to  the  extensor  digitorum. 

Step  I. — From  a  point  at  least  five  fingers'  breadth  above  the  intermalleolar 
space  make  a  median  incision  downwards.  Curve  the  lower  end  of  the  cut 
slightly  inwards.  Divide  the  skin  alone.  In  the  subcutaneous  tissue  of  the 
lower  part  of  the  wound  lie  the  terminal  filaments  of  the  musculo-cutaneous 
nerve.     Preserve  these  if  possible. 

Step  2. — Split  the  deep  fascia  throughout  the  whole  length  of  the  wound 
close  to  the  tendons  of  the  extensor  digitorum  and  peroneus  brevis  which  can 
be  seen  through  the  fascia.  Separate  the  extensor  digitorum  from  its  surround- 
ings for  a  short  distance  (Fig.  1325). 

Step  3. — ^From  a  point  slightly  below  the  external  malleolus  make  an  incision 
upwards  parallel  to  and  about  1/2  inch  behind  the  fibula  for  a  distance  of  5 
inches.  Incise  the  sheath  of  the  peronei.  Isolate  the  tendon  of  the  peroneus 
brevis.  Split  this  tendon,  carrying  the  split  as  high  up  as  possible,  in  such  a 
manner  as  to  divide  it  into  an  anterior  and  posterior  segment.  Divide  the 
anterior  segment  at  the  level  of  the  malleolus.  This  forms  a  flap  of  tendon 
having  its  base  above. 

Step  4. — With  forceps  and  knife  make  a  tunnel  from  the  wound  made 
in  Steps  i  and  2.  This  tunnel  must  hug  the  outer  side  of  the  fibula,  which  is 
bared  for  a  distance  of  about  2  to  3  inches.  Pull  the  flap  of  peroneus  brevis 
tendon  through  this  tunnel  so  that  it  now  lies  in  the  front  of  the  leg. 

Step  5. — Hold  the  foot  in  a  position  of  exaggerated  dorsal  flexion.  Pull 
the  extensor  communis  tendon  upwards  until  it  is  tense  and  then  make  a  longitud- 
inal button-hole  in  it.  Through  the  button-hole  pull  the  flap  of  the  brevis 
from  behind  forwards  and  suture  as  great  a  surface  as  possible  of  one  to  the 
other  (Fig.  1325). 

Step  6. — Close  all  the  wound  after  painstaking  hemostasis;  dorsal  flexion.* 

(B)  Transplantation  of  a  Slip  from  the  Extensor  Proprius  Hallucis 
to  the  Tibialis  Anticus. 

This  operation  may  be  performed  either  as  an  independent  procedure  or 
to  supplement  the  flexing  power  given  by  the  peroneus  brevis  to  the  extensor 
*  This  description  and  some  others  closely  follow  Berger  and  Banzet. 


TRANSPLANTATION. 


1089 


digitorum  as  described  in  the  previous  paragraphs.  Steps  i  and  2  as  in  the 
preceding  operation. 

Step  3. — Retract  the  edge  of  the  wound  inwards.  Expose  the  extensor 
proprius  hallucis  and  its  tendon.  Split  the  tendon  into  an  outer  and  an  inner 
segment.  Divide  the  outer  segment  transversely  at  the  level  of  the  annular 
ligament,  so  as  to  provide  a  tendon  flap  united  to  the  muscle  above  and  free 
below. 

Step  4. — Isolate  the  tendon  of  the  tibialis  anticus  and  pull  it  upwards,  flex- 
ing the  foot  dorsally.     Make  a  longitudinal  buttonhole  in  the  tendon.    Pull 


Fig.  1325. — {Berger  and  Banzet.) 


Fig.  1326. — {Berger  and  Banzet.) 


the  free  end  of  the  tendon  flap  (from  the  ext.  proprius  hallucis)  through  the 
button-hole  and  unite  it  there  as  in  figure  1326. 

II.  Talipes  Equinus  Due  to  Infantile  Palsy. 

The  tibialis  anticus  and  extensor  communis  digitorum  are  paralyzed. 
The  peroneus  brevis  is  not  available  as  a  donor  of  power.  The  extensor 
proprius  hallucis  is  healthy. 

Transplantation  of  a  Slip  from  the  Ext.  Proprius  Hallucis  to  the 
Extensor  Communis  Digitorimi.     Shortening  of  the  Tibialis  Anticus. 

Step  I. — ^From  a  point  at  least  five  fingers*  breadth  above  the  intermalleolar 
69 


1090 


TENDON   SHEATHS   AND    TENORRHAPHY. 


space  make  a  median  incision  downwards.  Curve  the  lower  end  of  the  cut 
slightly  inwards.  Divide  the  skin  alone.  Preserve,  if  possible,  the  terminal 
filaments  of  the  musculo-cutaneous  nerve  in  the  subcutaneous  tissue. 

Step  2. — Split  the  deep  fascia.  To  the  inner  side  of  the  tendon  of  the 
ext.  communis,  recognize  and  isolate  the  tendon  of  the  ext.  proprius  hallucis. 

Step  3. — Split  longitudinally  the  tendon  of  the  ext.  proprius  into  an  outer 
and  inner  segment.  Divide  the  outer  segment  transversely  at  the  level  of  the 
annular  ligament  (Fig.  1326). 

Step  4. — Pull  the  ext.  com.  digitorum  upwards,  strongly  flexing  the  foot. 
Make  a  longitudinal  button-hole  in  this  tendon  and  pull  through  the  button- 
hole the  mobilized  flap  provided  at  the  expense  of  the  ext.  proprius.  Suture 
securely. 


>■ 


Fig.  1327. — {Labey.) 


Fig.  1328. — (Labey.) 


Step  5. — Retract  the  inner  edge  of  the  wound  and  expose  the  tendon  of  the 
tibialis  anticus  and  shorten  it  in  the  same  manner  as  the  tendo  Achillis  is 
depicted  as  being  shortened  in  figures  1327,  1328,  1329,  1330. 

After  any  of  the  operations  such  as  have  been  now  described,  Robert 
Jones  endeavors  to  keep  the  united  tendons  free  from  tension  by  means  of  the 
removal  of  skin  flaps.  He  writes:  "Personally  I  see  that  the  deformity  of  the 
foot  is  overcorrected  before  any  operation  is  performed;  and  as  soon  as  the 
tendon  is  transplanted,  as  in  arthrodesis,  I  remove  an  oval  skin  flap  from  the 
paralyzed  side  so  large  that  when  the  edges  are  sewn  together  the  foot  remains 
fixed  in  an  overcorrected  position.  The  removal  of  the  skin  flap,  I  venture 
to  suggest,  gives  us  considerable  help  in  removing  strain  from  the  transplanted 
tendon.     The  foot  by  this  means,  as  I  have  before  said,  remains  in  the  desired 


PARALYTIC    CLUB-FOOT. 


IO9I 


position  in  spite  of  any  outside  influences."  The  reader  will  easily  see  how 
Jones's  method  may  be  applied  to  the  operation  here  described  and  how- 
valuable  it  is  calculated  to  prove. 

Regarding  tendon  transplantation  in  paralytic  club-foot,  Royal  Whitman 
writes:  "  Tendon  transplantation  is  most  efifective  from  the  curative  standpoint 
when  but  one  muscle  of  the  anterior  leg  group,  for  example  an  adductor  or 
abductor,  is  paralyzed.  The  most  common  form  of  this  milder  type  is  paralysis 
of  the  tibialis  anticus.  As  this  muscle  is  the  most  powerful  dorsal  flexor  and 
adductor  of  the  foot  its  loss  is  followed  by  secondary  equino-valgus.  In 
Parish's  operation  the  tendon  of  the  adjoining  extensor  proprius  pollicis  was 
simply  attached  to  that  of  the  tibialis  anticus,  but  as  the  extensor  of  the  great 


Fig.   1329.- — (Labey.) 


Fig.  1330. — (Labey.) 


toe  is  a  very  weak  muscle,  its  power  is  hardly  sufl&cient  for  the  double  task.  A 
more  efficient  procedure  is  to  split  the  tendon  of  the  paralyzed  muscle.  The  outer 
half  is  then  separated  from  its  muscular  attachment,  and  the  distal  extremity 
is  carried  across  the  foot  and  is  sutured  to  all  the  other  tendons.  The  proprius 
pollicis  is  then  attached  to  the  inner  half.  In  cases  of  longer  standing  and 
more  marked  deformity  it  is  well  to  reduce  the  power  of  the  abductors  by 
cutting  the  tendon  of  the  peroneus  tertius  from  its  insertion.  This  is  then 
drawn  beneath  the  other  tendons  and  is  attached  to  that  of  the  tibialis  anticus. 
All  of  the  tendons  on  the  front  of  the  ankle  may  then  be  sutured  to  one  another, 
so  that  all  may  act  as  direct  dorsal  flexors." 

"The  relative  strength  of  the  muscles,  as  well  as  their  function,  should  be 
considered  in  selecting  grafts,  and  in  prognosis  also.  According  to  Fick,  it 
is  as  follows,  in  kilogrammeters: 


1092  TENDON   SHEATHS  AND   TENORRHAPHY. 

Back  of  the  Leg. 

The  calf  muscle — gastrocnemius  and  soleus    8.21 

Tibilalis  posticus o.  40 

Peroneus  longus    o. 44 

Flexor  com.  digitorum    o-37 

Flexor  longus  pollicis o.  82 

10.24 

Front  of  the  Leg. 

Tibialis  anticus i .  61 

Extensor  proprius  pollicis    o.  39 

Extensor  longus  digitorum o.  72 

Peroneus  brevis 0.31 

Peroneus  tertius    o.  20 

3-23 

"The  importance  of  the  calf  muscle  on  the  back,  and  tibialis  anticus  on 
the  front  of  the  leg,  is  apparent.  The  former  is  nearly  four  times  as  strong 
as  the  combined  posterior  group,  the  latter  equal  to  all  the  others  on  the  front 
of  the  leg.  It  has  been  claimed  that  the  transplanted  muscle  may  become 
hypertrophied  and  that  its  strength  may  increase  sufficiently  to  carry  out  its 
new  function,  but  this  is  somewhat  doubtful." 

in.  The  muscles  of  the  calf  are  paralyzed.  Talipes  calcaneus  has  resulted. 
If  the  muscles  are  not  hopelessly  paralyzed,  an  application  of  Thomas' 
principles  and  prolonged  immobilization  of  the  leg  with  the  foot  in  a  position 
of  plantar  flexion  may  lead  to  regeneration.  It  is  most  important  to  remember 
this  and  to  avoid  immediate  recourse  to  what  may  be  a  needless  operation. 

(A)  Shortening  of  the  tendo  Achillis  has  been  frequently  employed  (Willett, 
Gibney,  and  others).  The  methods  of  tendon  shortening  are  sufificiently 
described  (p.  1080).  It  is  more  logical,  however,  to  supply  new  power  to  the 
tendon  rather  than  merely  to  shorten  it  until  it  acts  as  a  sort  of  passive  support 
to  the  heel. 

(B)  Transference  of  a  Tendon  Flap  from  the  Flexor  Longus  Digitorum 
to  the  Tendo  Achillis. 

Step  I. — From  a  point  about  i  inch  below  the  tip  of  the  internal  malleolus 
make  a  4-inch  incision  upwards  midway  between  the  tendo  Achillis  and  the 
posterior  border  of  the  tibia.     Expose  the  inner  border  of  the  tendo  Achillis. 

Step  2. — Split  the  tendo  Achillis  in  such  a  fashion  as  to  provide  a  tendinous 
flap,  2  1/4  inches  long,  free  above  and  attached  to  the  os  calcis  below. 

Step  3. — Incise  the  deep  fascia  parallel  and  close  to  the  posterior  border 
of  the  tibia.  Avoid  injury  to  the  sheath  of  the  tibialis  posticus  and  to  the 
vessels  which  lie  posterior  to  the  flexor  digitorum  and  between  it  and  the 


TENDON   TRANSFERENCE. 


1093 


flexor  proprius  hallucis.  Expose  and  isolate  the  tendon  of  the  flexor  longus 
digitorum  opposite  the  internal  malleolus. 

Step  4. — Divide  the  tendon  (flex,  digit.)  longitudinally  into  an  anterior  and 
posterior  segment.  Leave  the  anterior  segment  intact.  Divide  the  posterior 
segment  transversely  low  down  so  as  to  make  it  into  a  flap  with  pedicle  above. 

Step  5. — Put  the  ankle  in  a  position  of  great  plantar  flexion.  Lay  the  two 
flaps  obtained  from  the  tendo  Achillis  and  the  long  flexor  alongside  each 
other  and  unite  them  by  sutures  (Fig.   133 1). 

Step  6. — Shorten  the  intact  portion  of  the  tendo  Achillis. 


Fig.   1331. — \Berger  and  Bauzet.) 
V.  Vessels.     L.  FL.  Flexor  longus.     t.  a.  Tendo  Achillis.     i.  Intact  portion  tendon  of 
flexor  longus.     3.  Flap  from  tendo  Achillis.     2.  Flap  from  long  flexor. 

Step  7. — Close  the  wound.  Dress.  Immobilize  in  a  position  of  plantar 
flexion. 

(C)  Transference  of  a  Tendon  Flap  from  the  Peroneus  Longus  to 
the  Tendo  Achillis. 

Step  I, — ^From  a  point  about  i  inch  below  the  external  malleolus  make  a 
4-inch  incision  upwards  between  the  fibula  and  the  tendo  Achillis. 

Step  2. — Expose  the  outer  border  of  the  tendo  Achillis  and  from  it  fashion 
a  substantial  flap — about  2  1/4  inches  long— free  above,  united  to  the  os 
calcis  below. 

Step  3. — Incise  the  deep  fascia  parallel  and  close  to  the  posterior  border 
of  the  fibula.  Expose  and  open  the  sheath  of  the  peronei  muscles.  The 
tendon  of  the  p.  longus  lies  posterior  to  that  of  the  brevis. 


I094  TENDON    SHEATHS   AND    TENORRHAPHY. 

Step  4. — Split  the  tendon  into  an  outer  and  inner  segment.  Leave  the 
outer  segment  intact.  Divide  the  inner  segment  transversely,  low  down 
below  the  malleolus,  so  as  to  form  a  flap  with  its  pedicle  above. 

Step  5. — Put  the  foot  in  a  position  of  equinus  and  hold  it  there.  Lay  the 
two  flaps  of  tendon  (from  the  peroneus  longus  and  from  the  tendo  Achillis) 
alongside  each  other  and  unite  them  with  sutures. 

Step  6. — Shorten  the  intact  portion  of  the  tendo  Achillis. 

Step  7. — Close  the  wound.     Dress.     Immobilize  in  a  position  of  equinus 

(Fig.  1332). 

(D)  A  combination  of  operations  B  and  C  may  be  employed. 


'•»#.,  J'■^^f' 


Fig.   1332. — [Berger  and  Banzet.) 
L.  p.  Peroneus  longus.     t.  a.  Tendo  Achillis.     c.  p.  Peroneus  brevis.     i.  Intact  portion 
tendon  peroneus  longus.     2.  Flap  from  peroneus  longus.     3.  Flap  from  tendo  Achillis. 

(E)  Transference  of  slips  from  the  tibialis  posticus  and  peroneus  longus 
to  the  paralyzed  tendo  Achillis. 

Step  I. — Make  the  forked  incision  A  B  C  D  (Fig.  1333).  Reflect  the  flaps 
A  B  C,  A  B  D,  C  B  D.  In  doing  this  preserve  and  retract  the  external 
saphenous  vein  and  nerve  which  lie  at  the  outer  side  of  the  tendo  Achillis. 

Step  2. — Split  the  fascia  so  as  to  expose  the  outer  edge  of  the  tendo  Achillis. 
Freely  split  open  the  sheath  of  the  peronei. 

Step  3. — Divide  the  tendon  of  the  peroneus  longus  into  an  anterior  and 
posterior  segment.  The  muscle  fibres  are  inserted  into  the  tendon  in  the 
pennate  fashion,  therefore  it  is  easy  to  continue  the  cut  in  the  tendon  upwards 


TENDON    TRANSFERENCE. 


1095 


SO  as  to  form  two  muscular  bellies  each  attached  to  a  slip  consisting  of  half 
of  the  tendon  (Fig.  1334).  Carefully  avoid  injury  to  any  nerves  entering  the 
muscle.  Transversely  divide  the  posterior  slip  of  tendon  as  low  down  as 
possible. 

Step  4. — Make  a  longitudinal  cut  into  the  outer  side  of  the  tendo  Achillis. 
Retract  the  edges  of  the  cut  so  as  to  form  a  gutter  (Fig.  1334).  Implant  the 
mobilized  posterior  segment  or  slip  of  peroneus  tendon  into  the  gutter  in  the 
tendo  Achillis  and  fix  it  there  by  sutures  (Fig.  1335). 

Step  5. — Split  the  fascia  on  the  inner  side  of  the 
tendo  Achillis.  Retract  the  tendon  outwards  to  expose 
the  deep  fascia  under  which  can  be  seen  posterior  tibial 
vessels  and  nerves.  Split  the  deep  fascia  longitudinally 
internal  to  the  vessels  and  nerves;  retract  these  struc- 
tures. This  exposes  the  tibialis  posticus  in  the  depth 
of  the  wound  (Fig.  1336). 

Step  6. — Isolate  and  split  the  tendon  of  the  tibialis 
posticus;  imbed  one  of  the  segments  into  the  tendo 
Achillis  exactly  as  was  done  with  the  peroneus  longus. 
During  all  these  procedures  the  foot  must  be  held  in 
a  position  of  over-correction. 

Step  7. — Close  the  wound.  Dress.  Immobilize  in 
a  position  of  over  correction. 

(F)  The  flexor  proprius  hallucis  may  be  implanted 
into  the  tendo  Achillis  by  an  operation  almost  identical 

with  that  for  the  tibialis  posticus,  and  implantation  of  the  peroneus  brevis  is 
almost  identical  with  that  of  the  longus. 

IV.  The  abductors  of  the  foot  (extensor  communis  digitorum,  peroneus 
longus  and  brevis)  are  paralyzed.     The  foot  assumes  the  position  of  varus. 

(A)  Transference  of  power  to  the  peronei  by  means  of  a  slip  of  tendon 
derived  from  the  tendo  Achillis.  (The  following  description  closely  follows 
that  of  Labey,  "Chir.  du  Membre  inferieur.) 

Place  the  patient  on  his  sound  side  in  the  latero-ventral  posture.  Flex 
the  leg  on  the  thigh.     Have  an  assistant  hold  the  foot. 

Step  I. — ^From  a  point  1/2  inch  below  the  level  of  the  point  of  the  malleolus, 
cut  upwards  midway  between  the  posterior  border  of  the  external  malleolus 
and  the  external  border  tendo  Achillis,  to  the  level  of  the  middle  of  the  calf. 
Expose  and  retract,  uninjured,  the  external  saphenous  vein  and  nerve. 

Step  2. — Expose  and  free  the  outer  border  of  the  tendo  Achillis.  In  the 
upper  part  of  the  wound  expose  the  muscular  belly  of  the  outer  head  of  the 
gastrocnemius  and  working  from  above  downwards  separate  it  from  the  soleus 
until  a  point  is  reached  where  their  fusion  is  complete  and  further  separation 
is  impossible.     Relax  the  tendon  by  plantar  flexion  of  foot. 

Step  3. — With  a  knife  split  the  tendo  Achillis  as  in  figure  1337.  The  slip 
of  tendon  is  continuous  above  with  the  gastrocnemius,  but  is  free  from  the 


Fig.  17,7,7,.— (Labey.) 


1096 


TENDON   SHEATHS  AND   TENORRHAPHY. 


soleus.     Divide  the  slip  of  tendon  transversely  low  down  so  as  to  convert 
it  into  a  flap. 

Step  4. — Divide  the  fascia  covering  the  peronei  muscles  in  the  lower  three- 
fourths  of  the  wound.  Isolate  the  peroneus  longus  (superficial)  and  the  brevis 
(more  deeply  situated).  Retract  the  tendon  of  the  longus.  The  muscular 
fibres  of  the  brevis  are  inserted  into  a  flat  tendon  which  is  superficial  to  these 
fibres.  Make  a  longitudinal  split  penetrating  to  half  the  thickness  of  the 
muscle  and  retract  the  edges  of  this  split  so  that  the  peroneus  brevis  now 
forms  a  sort  of  gutter  into  which  the  tendon  of  the  longus  is  permitted  to  fall 
(Fig.  1335). 


Fig.   ziT,^.—  Labey.) 


.1^ 
Fig.   1335.— (Za6e;y.) 


Step  5. — Pull  the  mobilized  flap  of  tendon  Achillis  through  between  the 
peroneus  longus  and  brevis  (Fig.  1338),  and  fix  it  there  by  futures  as  in  figure 
1339.  When  bringing  the  tendon  flap  into  position  twist  it  carefully  in  such  a 
fashion  that  its  posterior  surface  (which  has  not  been  vivified  or  cut)  lies  against 
the  cut  surface  of  the  soleus  so  as  to  avoid  the  formation  of  adhesions. 

Step  6. — Close  the  wound.  Dress.  Immobilize  in  a  posture  of  plantar 
flexion  and  outward  rotation. 

V.  A  finger  flexor  tendon  is  lost.     Repair  by  transplantation. 


TENDON   TRANSFERENCE. 


1097 


Fig.  1336. — -(Labey.) 


Fig.   1337.— (ZaSe^y.) 


Fig.   i^t,8.— (Labey.) 


Fig.  1239.— (Labey.) 


ioqS 


TENDON   SHEATHS  AND   TENORRHAPHY. 


V.  Hacker  ("Bcitriige  zur  klin.  Chir.,"  Ixvi,  Hft.  2,  p.  279.  Ref.  "Journ. 
de  Chir.,"  May  10,  19 10)  reports  the  case  of  a  young  girl  who  lost  the  flexor 
tendons  of  the  middle  finger  as  a  result  of  a  deep  whitlow,  v.  Hacker  operated 
as  follows:  He  made  a  skin  flap  (Fig.  1340)  which  exposed  the  whole  palmar 
aspect  of  the  middle  finger  and  showed  the  complete  absence  of  the  flexor 
tendons.  Next  he  made  two  incisions  (Fig.  1341)  along  the  line  of  the  extensor 
communis  digitorum  over  the  second  metacarpal  bone.  Through  these  incisions 
he  split  the  tendon,  forming  a  long  flap  of  tendon  having  its  pedicle  near  the 
base    of    the    index    finger.     This    flap   he   passed   through   a   subcutaneous 


Fig.  1340 — {von  Hacker.) 


Fig.  1341 — {von  Hacker.) 


tunnel  to  the  palmar  aspect  of  the  middle  finger  and  sutured  its  end  to  the 
periosteum  of  the  ungual  phalanx.  To  avoid  peritendinous  adhesions  he 
surrounded  the  transplanted  tendon  with  a  piece  of  freshly  removed  hernial 
sac  and  in  the  middle  of  the  finger  sutured  across  the  tendon  a  band  of  fibrous 
tissue  obtained  from  the  debris  of  the  tendon  sheath  destroyed  by  the  whitlow. 
The  wounds  were  sutured  and  healing  took  place  by  first  intention.  Sixteen 
days  later  the  stump  of  the  old  flexor  tendon  was  exposed  in  the  palm  and 
sutured  to  the  proximal  end  of  the  transplanted  flap  of  tendon  which  was  of 
course  divided  from  its  old  connections  on  the  dorsum  of  the  hand.  Closure 
of  the  wound  and  immobilization  in  a  position  of  flexion  was  followed  by  heal- 
ing.    Eighteen  months  later  the  patient  could  close  her  fist  completely. 

VI.  There  is  paralytic  eversion  of  the  leg  necessitating  the  use  of  apparatus 


PARALYTIC    EVERSION    LEG. 


1099 


which  must  be  fastened  to  a  pelvic  band.     To  obviate  the  necessity  of  apparatus 
G.   G.   Davis  proceeds  as  follows: 

(a)  The  Tensor  Fasciae  Femoris  muscle  is  not  paralyzed.     Make  a  vertical 
incision  about  2  1/2  inches  in  length  down  to  the  great  trochanter  near  its 
anterior  edge.     From  this  cut  elevate  the  peri- 
osteum backwards  for  a  short  distance.     Under-  ,----, ^ 

mine  the  skin  anteriorly  to  the  wound  and  expose 
the  tensor  fasciae  femoris  at  its  insertion  between 
the  layers  of  the  fascia  lata.  Make  a  flap  of 
the  muscle  with  its  pedicle  above.  Unite  the 
free  end  of  the  muscle  flap  to  the  posterior 
(elevated)  edge  of  the  periosteal  wound. 

(b)  The  tensor  fasciae  femoris  is  paralyzed. 
Expose    the    trochanter   major   as   already   de-   • 

scribed.  Undermine  the  skin  forwards  from  the  original  incision,  exposing  the 
fascia  lata.  At  an  appropriate  distance  in  front  of  the  trochanter  major  incise 
(A  B,  Fig.  1342)  the  fascia  parallel  to  the  incision  in  the  periosteum  (C  D)  unite 
the  posterior  edge  of  the  periosteal  wound  C  D  to  the  anterior  edge  of  the 
fascial  wound  A  B  by  the  sutures  xx'-yy'-zz'. 


Fig.  1342 


CHAPTER  ex. 
TENOTOMY. 

There  are  two  methods  of  performing  tenotomy:  (A)  The  open  operation; 
(B)  the  subcutaneous  operation. 

(A)  Open  Operation. — Make  an  incision  of  sufficient  length  to  expose 
the  parts  to  be  divided.  Usually  this  cut  is  made  parallel  to  the  tendon. 
Isolate,  by  blunt  and  sharp  dissection,  the  segment  to  be  divided.  Retract 
surroundino;  structures.     Sever  the  tendon.     Close  the  vsround.     If  it  is  im- 


FiG.  1343. — Jones's  Tenotome. 


possible  or  improper  to  isolate  the  offending  structure,  expose  it  by  retracting 

the  edges  of  the  superficial  wound,  and  then  make  the  section,  cautiously  and 

with  small  cuts,  under  guidance  of  the  eye. 

(B)  Subcutaneous     Operation. — ^For    this     operation     small,     narrow- 

bladed  knives  (tenotomes)  are  necessary.     Usually  a  sharp-pointed  straight 

tenotome   suffices,    but   a   probe-pointed   instrument   is   occasionally   useful. 

The  shorter  and  narrower  the  blade,  the  better  it  is,  so  long  as  it  is  sufficiently 
strong  (Figs.  1343,  1344).  The  advantages  of  subcutaneous 
tenotomy  are  (o)  diminished  danger  of  infection;  (b)  absence 
of  scar.  The  dangers  of  injury  to  neighboring  important 
structures  are  slight,  and  in  most  localities  easily  avoided. 
Tenotomy  of  Tendo  Achillis  (Achillo-tenotomy) . — i. 
Cleanse  the  foot  and  leg,  and  turn  them  over  on  to  the 
outer  side.  By  palpation  locate  the  most  accessible  part  of 
the  tendon.  (The  position  of  choice  for  section  is  1/2  inch 
above  the  insertion  in  infants  and  i  1/2  inches  in  adults.) 

2.  Introduce  a  sharp-pointed  tenotome  through  the  skin 
under,  i.  e.,  anterior  to,  the  tendon.     Keep  the  flat  surface 

of  the  tenotome  parallel  to  the  tendon. 

3.  Turn  the  cutting-edge  of  the  tenotome  against  the  tendon. 

4.  Have  the  assistant  flex  the  foot  until  the  tendon  is  tense. 

5.  Press  the  tenotome  against  the  tendon  and  by  a  slight  levering  motion 
divide  it.     Take  care  not  to  injure  the  skin. 

IIOO 


Fig.  1344. 


TENOTOMY.  IIOl 

6.  Withdraw  the  knife  after  turning  its  blade  once  more  parallel  to  the 
tendon.     Apply  dressings. 

N.  B. — Beginners  frequently  perforate  the  tendon  with  the  tenotome  and  do  not  get 
complete  division.  Many  surgeons  in  Step  2  pass  the  tenotome  behind  the  tendon  and  cut 
forward ;  others,  having  made  a  passage  along-side  the  tendon  with  the  sharp-pointed  tenotome, 
substitute  a  probe-pointed  one  of  the  division  of  the  tendon. 

Tenotomy  of  Tibialis  Anticus. — This  tendon  is  usually  divided  near  its 
insertion  into  the  internal  cuneiform.  The  surgeon  stands  on  the  opposite 
side  of  the  leg  to  that  of  the  tendon.  The  assistant  grasps  the  leg  and  the  foot 
in  his  hands.  Abduction  and  plantar  flexion  demonstrate  the  position  of  the 
tendon. 

Step  I. — Place  tips  of  fingers  on  the  opposite  edge  of  tendon. 

Step  2. — Introduce  the  tenotome  through  the  skin  a  short  distance  from  the 
proximal  edge  of  the  tendon. 

Step  3. — Change  the  direction  of  the  knife  and  pass  it  horizontally  over  the 
tendon  until  its  point  is  felt  by  the  finger  guarding  the  opposite  side. 

Step  4. — Have  the  assistant  make  the  tendon  tense  (abduction  and  plantar 
flexion  of  foot). 

Step  5. — Turn  tlie  edge  of  tenotome  against  the  tendon  and  divide  it. 

Step  6. — Withdraw  tenotome.     Dress  in  a  position  of  eversion. 

Tenotomy  of  Tibialis  Posticus. — Point  of  division  should  be  about  i  1/2 
inches  above  the  internal  malleolus.  The  surgeon  stands  in  same  position 
as  in  tenotomy  of  the  tibialis  anticus.  Demonstrate  the  tendon  by  abduction 
and  plantar  flexion  of  the  foot. 

Jacobson  writes:  "In  fat  infants  it  is  often  quite  impossible  to  feel  the 
tendon,  and  in  these  cases  a  spot  midway  between  the  anterior  and  internal 
borders  of  the  leg  \\dll  be  the  best  guide,  as  denoting  the  inner  margin  of  the 
tibia.  The  surgeon  then  introduces  a  sharp  tenotome  so  as  just  to  touch, 
if  possible,  the  inner  margin  of  the  tibia,  taking  care  to  sink  the  blade  sufficiently 
to  open  the  sheath  freely.  This  being  done,  a  blunt  tenotome  is  introduced 
through  the  same  opening,  and  pushed  under  the  tendon ;  the  edge  being  then 
turned  towards  it,  and  the  tibia  used  as  a  fulcrum,  the  tendon  is  severed, 
together  with  that  of  the  flexor  longus  digitorum." 

Division  of  Plantar  Fascia. — The  plantar  fascia  may  be  divided  in  several 
places:  immediately  in  front  of  its  origin  from  the  os  calcis;  beside  the  transverse 
crease  which  is  present  in  all  marked  cases  of  plantar  contracture,  or  in  any 
line  which  may  seem  suitable.  Division  in  more  than  one  place  may  be  neces- 
sary before  satisfactory  results  are  obtained. 

Step  I. — The  assistant  makes  the  fascia  tense,  and  the  surgeon,  by  palpa- 
tion, satisfies  himself  as  to  its  "geography." 

Step  2. — A  tenotome  is  introduced  through  the  skin,  at  the  inner  side  of 
the  fascia  (the  fascia  is  not  kept  tense  at  this  stage),  and  passed,  with  its  flat 
surface  parallel  to  the  skin,  between  the  skin  and  fascia  across  the  sole 
until  its  point  is  beyond  the  outer  edge  of  the  fascia. 


II02 


TENOTOMY. 


Step  3. — The  cutting-edge  of  the  tenotome  is  turned  against  the  fascia, 
now  made  tense  by  the  assistant,  and  this  structure  is  divided. 

Step  4. — The  tenotome  is  withdrawn,  suitable  dressings  applied,  and  the 
foot  immobilized  in  a  position  of  overcorrection. 

CLUB-FOOT. 

A  clear  distinction  must  be  drawn  between  congenital  club-foot  and  that 
form  which  results  from  paralysis  acquired  before  or  after  birth.  In  the 
former  when  correction  or  rather  overcorrection  of  the  deformity  has  been 
completed  and  established,  all  has  been  done;  in  the  paralytic  form  after  deform- 


FiG.  1345- — {Berger  and  Banzet.) 


Fig.  1346. — {Berger  and  Banzet.) 


ity  has  been  corrected  it  may  be  necessary  to  resort  to  tendon  transplantation, 
etc.,  before  a  satisfactory  result  is  obtained. 

Congenital  Club-foot. — Talipes  Equino-varus. — Many  cases  of  equino- 
varus  may  be  successfully  treated  without  operation  if  taken  early  enough.  If 
an  intelligent  mother  or  nurse  by  manipulation  endeavors  to  mold  the  deformed 
foot  into  good  shape  (unwind  the  deformity)  and  does  this  patiently  3  or  4 
times  daily,  a  cure  will  often  be  obtained.     Figures  1345,  1346,  1347,  1348,  show 


Fig.   1347. — {Berger  and  Banzet.) 

how  the  modeling,  molding,  or  unwinding  ought  to  be  done.  In  other  cases 
the  surgeon  may  attain  the  same  result  more  rapidly  by  forcible  rectification 
(in  one  or  more  sittings)  and  by  keeping  the  foot  in  the  corrected  or  overcor- 
rected  position  by  means  of  a  plaster  of  Paris  dressing  until  the  new  position 
is  well  established. 

A  cardinal  rule  is  that  overcorrection  must  be  obtained,  otherwise  relapse 
is  the  rule;  but  overcorrection  is  not  all.     "No  case  of  dub-foot  is  cured  until 


CLUB-FOOT. 


IIO- 


the  patient  can  voluntarily  raise  his  own  foot  from  the  deformed  into  the 
overcorrected  position.  There  are  three  causes  of  so-called  relapse  in  club- 
foot: (i)  Insufficient  correction  of  deformity.  (2)  Erroneous  deflection  of 
bodyweight  on  tarsus  when  walking.  (3)  A  slack  and  lengthened  condition 
of  muscles  due  to  overstretching"  (Robert  Jones). 


Fig.   1348. — {Berger  and  Banzet.) 

Forcible  Rectification. — The  necessary  force  may  be  appHed  either  by 
the  hands  or  by  a  wrench.  Tenotomy  of  the  tendo  Achillis  is  usually,  and  of 
the  plantar  fascia  frequently,  a  necessity  immediately  before  the  forcible 
rectification. 

Manual  Rectification. — Step.i — Grasp  firmly  in  one  hand  the  heel  and 


Fig.  1349.— (Ifo/a.) 

ankle,  in  the  other  the  distal  end  of  the  foot,  leaving  the  region  of  the  calcaneo- 
cuboid articulation  unsupported  by  the  hands.  Lay  the  convex  surface  of 
this  portion  of  the  foot  against  the  edge  of  a  wedge  of  wood  covered  by  a  towel. 
The  wedge  acts  as  a  fulcrum  (Fig.  1349). 

Step  2. — Apply  force,  even  the  whole  weight  of  the  body,  to  straighten  or 


II04  TENOTOMY. 

unfold  the  foot  by  compressing  its  convex  side  against  the  fulcrum  and  stretching 
or  tearing  the  structures  on  the  concave  side.  In  young  children  overcorrection 
is  often  possible  in  one  sitting.  Care  must  be  taken  not  to  tear  the  skin.  If 
the  skin  seems  about  to  tear,  put  off  further  correction  until  another  time, 
when  it  will  be  found  to  have  accommodated  itself  to  the  changed  circumstances. 
If  the  desired  result  is  not  obtained  in  one  sitting,  a  second,  third,  or  fourth 
operation  should  be  done  at  intervals  of  about  a  week. 

Before  the  anagsthetic  is  discontinued,  envelop  the  foot  in  a  plaster-of-Paris 
dressing.  To  avoid  trouble  from  swelling  of  the  foot  owing  to  the  trauma  it  is 
well  to  keep  the  limb  elevated  for  twenty-four  hours. 

Remember  that  Overcorrection  is  the  Aim. — Ridlon  always  uses  forcible 
rectification  with  tenotomies,  and  division  of  fascia  and  ligaments  as  may  be 
required.     He  says,  "Put  on  thick  layers  of  cotton  batting  with  bandage  over — 


Fig.  1350. 

this  must  be  smooth,  so  as  to  prevent  ridges  being  formed  on  inside  of  the  plaster 
which  is  now  applied  thick,  so  thick  that  patient  may  walk  on  it  for  four  or  five 
months.  Don't  change  the  dressing.  Don't  operate  before  the  walking  age. 
Sometimes  the  thick  bandages  will  come  off,  i.  e.,  slide  off.  If  this  is  the  case, 
smoothly  pad  the  lid  of  a  cigar  box  fashioned  to  shape  of  sole  and  fix  it  to  the  foot 
by  adhesive  straps,  then  apply  the  plaster.  The  whole  foot  and  leg  is  wrapped 
with  the  cotton  before  the  wood  foot-piece  is  applied.  The  plaster  goes  to 
about  the  knee  and  must  be  thick.  The  test  of  cure  is  that  when  the  plaster 
cast  is  removed  the  foot  remains  in  overcorrected  position  and  cannot  without 
force  be  put  into  malposition.     Operate  at  any  age." 

Instrumental  Rectification. — The  best  instrument  for  applying  force  in  the 
rectification  of  club-foot  is  Thomas'  wrench  (Fig.  1350)  employed  as  Thomas 
used  it.  The  wrench  is  applied  to  the  foot  and  the  foot  is  twisted  and  bent  in 
the  normal  directions.  The  correction  must  be  accomplished  forcibly  and 
quickly  and  the  foot  immediately  released.  Holding  the  foot  too  long  in  the  bite 
of  the  wrench  may  result  in  a  pressure  sore  (Ridlon  and  Jones).  Apply  force 
sufl5ciently  to  temporarily  destroy  the  resiliency  of  the  soft  parts  so  that  the  foot 
lies  in  the  hand  of  the  operator.  Place  in  good  position  in  a  retention  brace. 
After  a  few  days  the  resiliency  of  the  soft  parts  begins  to  return  and  the  operation 
is  repeated  if  this  is  necessary  to  obtain  overcorrection,  and  there  is  no  tendency 
towards  recurrence.  After  this  keep  the  foot  immobilized  until  all  the  parts 
have  adapted  themselves  to  their  new  relations;  or,  as  Thomas  said,  "until  the 
slack  has  been  taken  up  and  the  flexors  and  evertors  of  the  ankle  voluntarily 


CLUB-FOOT. 


II05 


act."  Ridlon  writes:  "If  the  patient  cannot  voluntarily  flex  and  evert,  it  is 
because  the  tendons  concerned  are  still  suffering  from  stretch  palsy,  and  relapse 
will  occur  exactly  as  deformity  arises  in  poliomyelitis.  (Figures  1351,  1352, 
1353,  show  the  application  of  R.  Jones's  iron  club-foot  splints.) 

In  some  obstinate  cases  of  club-foot  the  tendo  Achillis  pulls  upwards  on  the 
inner  side  of  the  tuberosity  of  the  calcaneum  to  an  unusual  extent  and  thus 
hinders  or  prevents  correction  of  varus.  Under  these  circumstances  R.  Jones 
.  by  transplantation  moves  the  insertion  of  the  tendo  Achillis  outwards  in  the 
following  manner:  Expose  the  tendo  Achillis  by  a  T-shaped  incision  (Fig.  1354). 
Split  the  tendon  longitudinally.     Separate  the  inner  half  of  the  tendon  from  its 


Fig.   1351. —  {Jones.) 


Fig.   1352. —  iJones.^ 


insertion.  Pass  the  inner  segment  of  tendon  (now  a  flap  with  pedicle  above) 
under  the  outer  (Fig.  1355)  segment  and  suture  its  free  end  to  the  periosteum  of 
the  OS  calcis  outside  and  in  immediate  juxtaposition  to  the  still  attached  half. 
The  opposing  surfaces  of  tendon  should  be  vivdfied  and  sutured  together. 

Phelp's  Operation. — Preliminary  Treatment.— If  the  patient  has  walked, 
large  callosities  will  be  present  on  the  foot;  to  soften  and  clean  these  soap  poul- 
tices should  be  applied  for  twenty-four  hours;  twelve  hours  before  the  operation 
the  foot  must  be  thoroughly  scrubbed  and  an  antiseptic  fomentation  applied. 

Step  I.— Render  limb  avascular  by  elevation  and  apply  tourniquet.  Place 
the  foot,  with  outer  side  downwards,  on  a  sand-bag.  Have  the  assistant  hold  the 
heel  firmly.  Grasp  the  distal  portion  of  the  foot  and  make  the  plantar  tissues 
tense. 

Step  2.— On  the  inner  side  of  the  foot  make  an  incision  beginning  directly 
in  front  of  the  malleolus  and  ending  one-fourth  of  the  distance  across  the  sole 
70 


iio6 


TENOTOMY. 


of  the  foot.     Divide  all  resisting  structures,  penetrating  to  the  bone  if  necessary. 
(See  Fig.  1356;  here  the  cut  is  being  made  from  the  sole  to  the  malleolus.) 
Step  3. — By  manipulation  complete  the  overcorrection  of  the  varus. 


i''i«-   ^2Si-— {Jones.) 

Step  4. — Correct  the  equinus  by  Atenotomy  of  tendo  Achillis. 
Step  5. — Pack  the  wound  with  sterile  iodoform  gauze.     Dress.     Immobilize 
in  a  position  of  overcorrection  by  a  plaster-of-Paris  bandage,  which  reaches 


Fig.  1354. 


Fig.  1355. 


well  u.p  the  calf.     WTiile  the  plaster  is  hardening,  hold  the  foot  in  its  new  position 
by  means  of  a  flat  board  laid  against  the  sole. 

Step  6. — Remove  the  tourniquet.     Elevate  the  limb  for  twenty-four  hours. 


CLUB-FOOT. 


II07 


If  cleanliness  has  been  attained,  the  dressings  may  be  left  untouched  for  from 
two  to  three  weeks,  when  the  wound  wdll  generally  be  found  practically  healed. 

Tarsectomy. — Occasionally  the  above  operation  may  be  found  insufficient 
to  produce  overcorrection.  Having  divided  the  soft  parts  as  described,  cut 
through  the  neck  of  the  astragalus  with  a  chisel.  In  packing  the  wound  do 
not  introduce  the  gauze  into  the  cleft  in  the  bone. 

After-treatment. — Plaster  of  Paris,  renewed  when  necessary,  should  be 
worn  for  from  six  to  eight  weeks,  after  which  massage  and  exercises  should  be 
used  and  a  good  strong  shoe  worn.  As  a  rule,  no  special  club-foot  shoe  is 
necessar}^  after  the  Phelps  operation. 

Jonas's  Operation. — A.  F.  Jonas  ("Annals  of  Surg.,"  April,  1899)  thus 
describes  his  method:     "An  incision  is  made,  beginning  slightly  below  the  mar- 


FlG. 


gin  of  the  plantar  fascia  on  the  inner  side  of  the  foot,  at  a  point  on  a  line  directly 
below  and  anterior  to  the  internal  malleolus,  extending  forwards  and  upwards  to  a 
point  on  the  first  metatarsal  bone  and  nearly  to  the  metatarso-phalangeal  articu- 
lation. A  second  incision  is  made,  beginning  at  a  point  over  the  astragalo- 
scaphoid  articulation,  extending  forwards  and  slightly  downwards,  joining  the 
first  incision  near  the  metatarso-phalangeal  joint,  forming  a  V(Fig.  1357).  The 
incisions  are  made  deep,  so  as  to  include  the  subcutaneous  tissues  and  fat." 
Dissect  back  the  flap  thus  outlined.  Sever  diagonally  the  inner  fasciculus  of 
the  plantar  fascia.  Divide  the  remaining  structures  successively,  as  directed 
by  Phelps.  Do  not  injure  the  astragalo-scaphoid  capsule.  Make  another 
incision  on  the  outer  side  of  the  foot  over  the  head  of  the  astragalus,  and  with 
a  chisel  divide  the  neck  of  that  bone,  if  necessary,  removing  the  head.  Over- 
correction is  now  easy.  Ligate  the  bleeding  points.  Replace  the  triangular 
flap  (Fig.  1359).  Do  not  suture.  Cover  the  wound  with  perforated  oiled  silk. 
Dress.     Immobilize  in  a  plaster  of  Paris  bandage  which  reaches  one-third  up  the 


iio8 


TENOTOMY. 


thigh.     Leave  dressings  undisturbed  for  five  or  six  weeks.     This  method  is 
only  suitable  in  "old,  inveterate,  and  relapsing  cases." 

Lorenz  (Konig,  "Lehrbuch  der  speciellen  Chir.,"  iii,  809)  gives  the  following 
list  of  operations  for  club-foot,  in  which  the  bones  are  attacked : 

(A)  Osteotomies. 

(i)  Linear  division,  navicular  bone  from  the  sole  (Hahn). 

(2)  Linear  division,  tibia  and  fibula  above  the  ankle. 

(B)  Enucleation, 
(a) Of  one  bone: 

(3)  Of  the  cuboid  (Solly). 

(4)  Of  the  astragalus  (Lund,  Mason). 


Fig.  1357. — {Jonas.) 


Fig.  1358. — {Jonas.) 


(5)  Of  the  astragalus  with  resection  of  the  point  of  the  external 

malleolus  (Mason,  Ried). 

(6)  Curettement  of  the  spongy  part  of  the  astragalus,  leaving  the 

articular  surfaces  intact  (Verebely). 

(7)  Of  the  astragalus  plus  removal  of  a  wedge  with  base  external 

from  the  anterior  process  of  the  calcaneum  (Hahn). 

Meussel's  operation  of  extirpation  of  ossifying  centres  of  the  astragalus  in 
young  children. 

(b)  Of  several  bones. 

(8)  Enucleation  of  astragalus  and  cuboid  (Hahn,  Albert)  and  of  the 

navicular  bone  (West). 

(9)  Enucleation  of  the  navicular  and  cuboid  (Bennet). 
(C)  Resections. 

(10)  Of  the  head  of  the  astragalus  (Liicke,  Albert). 

(11)  Of  a  portion  of  bone  from  the  external  half  of  the  neck  of  the 

astragalus  (Hueter). 


CLUB-FOOT.  1 109 

(12)  Resection  of  a  wedge  from  the  outer  and  upper  sides  of  the 

tarsus  (O.  Weber,  Davis  Colley,  R.  Davy,  Schede,  Meussel, 

etc.). 

(13)  Resection  of  two  wedges  perpendicular  to  each  other  with  their 

bases    directed    outwards   from  the  astragalo-calcaneal  and 
Chopart's  joints  (Rydygier). 

Occasionally  the  fibula  occupies  a  position  to  far  back  near  the  tendo 
Achiilis,  the  space  between  the  internal  and  external  malleoli  is  too  narrow,  and 
the  anterior  portion  of  the  astragalus  is  too  wide.  This  state  of  affairs  is  an 
indication  for  excision  of  the  astragalus  (Konig). 

Astragalectomy. — i.  Apply  an  Esmarch  bandage. 

2.  Make  a  longitudinal,  slightly  curved  incision  2  inches  long  over  the  most 
prominent  part  of  the  head  of  the  astragalus  from  the  external  malleolus  down- 
wards and  inwards,  between  the  outermost  tendon  of  the  extensor  longus 
digitorum  and  the  peroneus  tertius.  Reflect  the  soft  parts  with  a  periosteal 
elevator. 

3.  Open  the  ankle  and  astragalo-scaphoid  joints.  Seize  the  bone  with  a 
lion -jawed  forceps,  loosen  it  with  an  elevator,  and  divide  its  ligaments  with 
strong,  blunt-pointed  scissors  or  the  scalpel. 

4.  Place  the  foot  in  good  position.  If  correction  cannot  yet  be  obtained, 
one  may  follow  Walsham's  advice  (Jacobson's  "Operations  of  Surg.,  ii,  711): 
*'  When  once  a  bone  operation  has  been  embarked  on,  it  is  no  use  stopping  short 
till  suflSicient  bone  has  been  cleared  away  to  permit  of  the  rectification  of  the  foot. 
No  more  should,  of  course,  be  removed  than  is  necessary,  but  to  take  away  too 
little  is  to  my  mind  the  graver  fault. 

Cuneiform  Tarsectomy. — The  operation  of  cuneiform  tarsectomy  consists 
in  making  a  longitudinal  incision  over  the  most  prominent  portion  of  the  tarsus, 
without  injury  to  the  tendons,  in  reflecting  the  soft  parts  to  lay  bare  the  bone, 
and  in  excising  a  wedge  of  bone.  The  steps  of  the  operation  do  not  require 
description;  the  surgeon  must  apply  Walsham's  rule,  quoted  in  the  previous 
paragraph,  and  also  make  use  of  common  sense. 

Ogston's  Operation  ("Brit.  Med.  Jour.,"  June  21,  1902).— This  operation 
is  similiar  to  that  of  Meussel,  and  is  suitable  in  bad  cases  of  club-foot  in  children 
up  to  the  sixth  or  possibly  the  eighth  year,  A  skiagraph  will  tell  if  ossification 
has  proceeded  too  far.  The  principle  of  the  operation  is  to  remove  the  osseous 
centres  from  those  bones  which  impede  rectification.  After  correction,  the 
remaining  envelope  of  cartilage  will  become  ossified.  "An  incision  through  the 
skin  is  made  in  a  gentle  curve  beginning  in  front  of  the  external  malleolus  and 
extending  forwards,  with  its  convexity  towards  the  sole,  imtil  it  terminates  over 
the  calcaneo-cuboid  joint  on  its  dorsal  aspect.  When  its  edges  are  retracted, 
the  outline  of  the  astragalus  is  visible.  The  soft  parts  covering  it  and  the  cartil- 
aginous shell  surrounding  its  osseous  centre  are  then  divided  by  a  shorter  in- 
cision in  the  same  line  as  the  cutaneous  one,  the  knife  being  made  to  sever  every- 


mo  TENOTOMY. 

thing  down  to  the  bony  kernel.  A  Volkmann's  spoon,  slightly  curved  forwards 
at  its  neck  is  passed  into  the  wound  of  the  cartilage,  and  its  whole  bony  centre, 
save  the  upper  part  constituting  the  pulley  between  the  two  malleoli,  is  cautiously 
scraped  out."  If  necessary,  the  same  treatment  may  be  applied,  through  the 
same  external  wound,  to  the  cuboid  and  anterior  end  of  the  os  calcis.  After 
removing  the  Esmarch  constrictor  and  attending  to  hemostasis,  close  the  wound 
with  deep  and  superficial  sutures  and  immobilize  with  plaster  of  Paris  in  correct 
position. 

The  following  remarks  are  based  on  material  placed  at  the  disposal  of  the 
writer  by  his  friend  Mr.  Robert  Jones,  of  Liverpool. 

Before  any  bone  operation  is  adopted  in  club-foot  one  should,  at  a  prelimi- 
nary sitting,  correct  the  deformity  as  much  as  possible  by  means  of  the  tenotome 
and  wrench.  Less  bone  will  then  have  to  be  removed  and  the  result  is  much 
more  artistic. 

In  club-foot  there  is  often  present  a  twist  in  the  leg.  This  rotation  is  en- 
tirely below  the  knee  and  confined  to  the  tibia  and  fibula.  Unless  this  deformity 
is  corrected  there  will  be  persistent  trouble  even  after  complete  correction  of  the 
equinus  and  varus.  "  It  is  therefore  well  to  anticipate  this  problem  the  moment 
we  begin  treatment.  Every  time  the  Equino-varus  is  manipulated  the  malleoli 
should  be  grasped  in  one  hand,  while  the  leg  should  be  held  below  the  knee  with 
the  other.  The  lower  ends  of  the  tibia  and  fibula  are  rotated  outwards  and 
the  knee  inwards.  The  leg  is  thus  twisted  on  its  long  axis  by  an  action  not  dis- 
similar to  that  used  when  one  wrings  a  wet  cloth.  If  this  is  done  each  day, 
by  the  time  the  foot  is  straight  the  inversion  of  the  foot  will  also  have  disappeared. 
No  club-foot  can  be  pronounced  cured  until  the  patient  walks.  Walking  is 
the  act  which  completes  the  cure." 

Sometimes  osteotomy  or  osteoclasis  is  necessary  to  correct  the  twist  in  the 
tibia  and  fibula. 

Mr.  Jones  sums  up  his  practice  in  the  treatment  of  club-foot  in  the  following 
words: 

"The  operation  I  perform  in  obstinate  cases  is  very  simple  and  can  be  com- 
pleted in  about  ten  minutes. 

"  (a)  The  removal  of  half  the  scaphoid. 

"(b)  The  removal  of  anterior  and  lower  part  of  astragalus  leaving  the  tibial 
articulation. 

"(c)   Osteotomy,  if  necessary,  through  outer  part  of  tarsus. 

"  (d)  Forcing  foot  into  everted  position  when  the  scaphoid  will  articulate 
with  the  remainder  of  the  astragalus. 

"The  simple  case  is  one  which  we  can  quite  easily  replace  in  good  position 
and  which  shows  but  little,  if  any,  adduction  at  the  mid-tarsal  joint.  Such  a 
case  will  probably  not  require  a  division  of  even  the  tendo  Achillis.  If,  how- 
ever, there  is  marked  adduction  at  the  mid-tarsal  and  a  rotation  inwards  of  the 
tibia  and  fibula,  the  case  may  be  looked  upon  as  afifording  the  surgeon  an  oppor- 
tunity for  work.     In  the  simple  case,  where  the  surgeon  cannot  pay  frequent 


CLUB-FOOT. 


nil 


visits,  the  nurse  should  be  taught  the  manipulations  which  she  can  practise  several 
times  a  day.  The  tibia  and  fibula  should  be  grasped  at  the  epiphysis  which 
may  othermse  easily  be  separated,  and  the  foot  should  be  alternately  everted 
and  flexed.  Following  this,  the  heel  should  be  grasped  in  one  hand  and  the 
anterior  portion  of  the  foot  in  the  other  and  abduction  secured  at  the  mid- 
tarsal  joint.  Five  minutes  spent  three  times  a  day  in  doing  this  should  be  fol- 
lowed by  gentle  massage  of  the  flexors  of  the  foot  and  the  peroneal  group.  This 
should  be  followed  by  the  application  of  a  bandage  or  of  a  rectangular  splint. 
Surgeons  often  fail  to  appreciate  how  much  can  be  done  by  the  simple  appli- 
cation of  a  calico  bandage.  If  the  surgeon  desires  to  turn  the  foot  in,  he  should 
start  the  bandage  on  the  outside ;  if  he  desires  to  evert  the  foot  he  should  begin 
on  the  inside.  In  the  case  of  eq.  varus  he  should  start  on  the  inner  side  of  the 
ankle,  pass  under  the  sole  of  the  foot,  over  the  front  of  the  ankle  and  so  evert  it. 


Fig.  1359. — {Jones.) 


Every  turn  of  the  bandage  so  applied  pulls  the  foot  outwards,  whereas,  if  the 
bandage  be  started  from  the  outer  side,  the  deformity  is  at  each  turn  increased. 
I  have  on  several  occasions,  for  demonstration  purposes  in  club-foot  of  moder- 
ate severity,  quite  overcome  and  cured  the  deformity  by  the  simple  expedient 
of  a  bandage.  Care  should  be  taken  if  a  bandage  be  used,  with  or  without  a 
splint,  not  to  carry  it  much  above  the  ankle  lest  the  muscles  be  thereby  weakened 
(Fig.  1359).  Should  the  surgeon  be  able  wdth  but  little  effort  to  restore  the  foot  to 
its  normal  position,  it  will  not  be  necessary  to  divide  a  tendon.  Should  the  degree 
of  resistance  be  more  marked,  division  of  the  tendo  Achfllis  becomes  imperative. 
A  great  deal  has  been  written  of  the  advantage  of  correcting  the  varus  before 
dividing  the  tendo  Achillis.     Although  in  full  possession  of  the  arguments 


III2 


TENOTOMY. 


for  this  view,  I  quite  fail  to  appreciate  their  force,  and  on  the  contrary  maintain 
that  the  Achilles  tendon  often  helps  to  perpetrate  the  inversion. 

"The  Club-foot  Shoe. — I  use  a  club-foot  shoe  which  I  have  modified  from 
the  Thomas.  The  details  of  its  application,  simple  as  they  appear,  require 
study.  It  can  be  made  by  any  country  blacksmith  at  a  very  trivial  cost.  It  is 
made  of  flexible  sheet-iron  (Figs.  1351,  1352,  1353).  After  the  foot  has  been  ma- 
nipulated into  the  best  possible  position,  a  piece  of  plaster  should  be  started  on 
the  dorsum,  passed  under  the  sole,  and  given  to  an  assistant  at  hand.  He 
should  be  directed  to  pull  at  right  angles  to  the  leg,  while  the  surgeon  places  the 
retention  splint  in  position.  This  should  be  done  for  fully  six  weeks,  either  by 
the  surgeon  or  someone  he  can  trust;  the  splint  being  changed  every  day.  I 
very  much  prefer  this  method  of  retention  to  that  of  plaster  of  Paris  which  I 
rarely  use.     At  the  end  of  two  months  the  most  troublesome  of  this  class,  i.  e., 


Fig.  1360. — {Jones.) 


cases  which  the  surgeon  sees  during  the  first  two  years,  will  present  a  pliable 
foot  which  can  be  placed  into  normal  position  without  encountering  resistance, 
and  if  the  child  be  suflficiently  old  be  can  be  taught  to  walk  in  such  a  manner 
that  each  step  he  takes  tends  to  improve  the  shape  of  the  foot." 

Talipes  Calcaneus  (Congenital). — In  this  form  of  club-foot  the  foot  is  in 
a  position  of  dorsal  flexion;  the  tendo  Achillis  is  elongated,  the  anterior  tendons 
are  contracted.  It  is  wise  to  begin  treatment  by  manipulation  a  few  days  after 
birth.  The  manipulation  consists  in  patiently  and  persistently  coaxing  the 
foot  into  a  position  of  plantar  flexion,  thus  stretching  the  anterior  tendons. 
As  soon  as  the  deformity  has  been  overcorrected,  apply  some  fixed  dressing  to 
retain  the  overcorrected  position  until  the  tendo  Achillis  has  had  time  to  con- 
tract. In  severe  cases  the  manipulation  may  be  carried  out  forcibly  under  an 
anaesthetic.     Tenotomy  of  the  anterior  tendons  is  very  rarely  necessary. 


ARTHRODESIS. 


III3 


Talipes  Cavus  (Hollow -foot). — The  arch  of  the  foot  is  unnaturally  high; 
the  anterior  part  of  the  foot  being  approximated  to  the  heel.  The  worst 
samples  of  the  deformity  are  those  produced  as  a  mark  of  beauty  in  the  Chinese 
women  of  high  rank.  Talipes  cavus  may  occur  along  with  the  other  forms  of 
club-foot.     Operation  is  only  required  in  severe  cases  and  consists  of  sub- 


FiG.  ii6i.- — {Jones.) 


Fig.  1 162. — {Janes.) 

cutaneous  division  of  the  plantar  fascia,  forcible  rectification  and  retention  in  a 
plaster  of  Paris  dressing,  until  such  time  as  the  corrected  position  is  established. 

Arthrodesis  for  Paralytic  Calcaneo-cavus. — Robert  Jones'  Opera- 
tion. 

I.  Paralysis  of  the  calf  muscles  is  complete. 

Operation  in  two  stages,  four  weeks  intervening. 


III4 


TENOTOMY. 


Stage  I. — Step  i. — If  the  plantar  fascia  is  contracted,  divide  it  subcutaneously 
and  straighten  the  sole  as  much  as  possible  by  manual  or  instrumental  force. 

Step  2. — On  the  inner  side  of  the  foot  make  a  3 -inch  incision  to  the  bone;  the 
centre  of  the  cut  being  opposite  the  angle  of  convexity.  Separate  the  soft 
parts  from  the  tarsus  with  an  elevator  until  the  inner,  dorsal,  and  plantar 
surfaces  are  accessible. 

Step  3. — With  a  chisel  remove  a  wedge  of  bone  (base  above  (Fig.  1360) 
(Robert  Jones,  "Am.  Journ.  Orthop.  Surg.,"  April,  1908)  large  enough  to 
completely  correct  the  cavus. 

Step  4. — Close  the  wound.  Correct  the  cavus  by  flexing  the  foot  dorsally 
(Fig.  1361)  and  after  applying  dressings  bandage  the  foot  to  the  tibia.  The 
cavus  is  cured,  but  the  calcaneus  is  apparently  much  worse. 


Fig.  1163. — (Janes.) 

Stage  II. — (Four  weeks  later). 

Step  I. — Make  a  longitudinal  cut  at  the  back  of  the  heel,  the  centre  being 
opposite  the  ankle-joint.     Open  the  joint. 

Step  2. — From  the  astragalus  cut  away  a  wedge  of  bone  sufficient  to  permit 
the  foot  being  brought  at  a  right  angle  to  the  leg  (Fig.  1362)  and  arthrodese 
to  tibia. 

Step  3. — Close  the  wound.  Correct  the  deformity  (Fig.  1363).  Apply  dress- 
ing.    Immobilize  until  union  is  complete. 

2.  The  paralysis  of  the  calf  muscles  is  not  complete. 

Stage  I. — As  in  previous  operation. 

Stage  II. — (Four  weeks  later). 

Step  I. — Opposite  the  ankle-joint  make  a  posterior  transverse  incision  long 
enough  to  expose  the  posterior  capsule  of  the  joint.  Reflect  the  skin  upwards 
and  downwards.  Place  and  hold  the  foot  in  good  position.  Shorten  the  elon- 
gated posterior  capsule  by  throwing  it  into  folds  and  fixing  the  folds  by  sutures. 


CLUB-FOOT. 


III5 


Step  2. — Shorten  the  tendo  Achillis. 

Step  3. — Excise  enough  skin  from  the  upper  and  lower  edges  of  the  transverse 
incision  so  that  when  sutures  are  introduced  and  healing  has  taken  place  the 
skin  itself  will  aid  in  maintaining  the  correct  position. 

Step  4. — Apply  dressings.  Immobilize,  After  three  weeks  begin  massage 
of  the  gastrocnemius.  "For  some  weeks  after  walking  has  commenced  the 
foot  should  be  protected  against  strain." 


CHAPTER  CXI. 
DUPUYTREN'S  CONTRACTURE. 

Dupuytren's  contracture  is  due  to  a  contraction  of  the  palmar  fascia  whereby 
the  fingers  become  fixed  and  incapable  of  extension.  The  ring  finger  is  first 
afifected.  The  fascia  is  normally  connected  by  bands  with  the  skin  of  the  palm. 
When  the  fascia  contracts,  the  skin,  being  adherent  to  it  at  points,  is  naturally 
thrown  into  wrinkles  and  folds.  Operation  is  indicated  when  the  deformity 
causes  distinct  disability.  In  a  handicraftsman  operation  will  be  called  for 
at  a  much  earlier  stage  of  the  disease  than  in  one  whose  work  does  not  demand 
free  use  of  the  hands, 

Adam's  Operation. — Clean  the  hand  thoroughly.  Note  the  points  where 
the  skin  is  not  closely  adherent  to  the  subjacent  fibrous  band.  At  such  places 
introduce  a  fine  tenotome  between  the  skin  and  the  fibrous  band.  Turn  the 
edge  of  the  tenotome  against  the  fibrous  hand.  Make  the  band  tense  by  extend- 
ing the  affected  finger,  and  at  the  same  time  give  a  slightly  sawing  motion  to 
the  tenotome.  Be  careful  not  to  cut  too  deeply  lest  the  flexor  tendons  be  injured. 
The  operation  must  be  repeated  at  several  points.  Apply  aseptic  dressings. 
Fix  the  hand  and  fingers  in  a  position  of  extension  by  means  of  a  dorsal  splint. 
After  the  lapse  of  three  weeks  careful  and  thorough  massage  is  indicated; 
the  splint  may  be  discarded  during  the  day,  but  a  suitable  appliance  to  maintain 
extension  must  be  worn  at  night  for  several  weeks. 

Recurrence  of  the  trouble  often  takes  place,  but  in  other  cases  the  result  is 
permanent  and  various  nodes  of  scar  tissue  or  callosities  disappear  in  a  surprising 
manner.  The  operation  is  simple,  can  be  performed  under  local  anesthesia, 
and  ought  to  be  tried  in  most  cases  before  more  severe  measures  are  adopted. 

Dupuytren's  Operation. — Cleanse  the  hand  thoroughly.  Extend  the 
affected  finger  as  much  as  possible.  Make  a  transverse  incision  one  inch  in 
length  opposite  the  metacarpo-phalangeal  joint.  This  incision  divides  both 
the  skin  and  the  contracted  fascia,  but  must  not  injure  the  flexor  tendons. 
Apply  aseptic  dressings.  Fix  the  hand  and  fingers  in  a  position  of  extension 
by  means  of  a  suitable  splint.  When  the  wound  has  healed,  the  treatment  to 
be  adopted  is  the  same  as  after  the  Adam's  operation. 

Open  Operation;  Hardie's  Operation. — "An  incision  is  begun  half  an 
inch  above  the  principal  transverse  fold  of  the  palm,  immediately  over  the  tense 
bridle  of  fascia,  proceeding  to  the  finger  mainly  involved.  This  is  carried  along 
the  bridle  to  a  littie  beyond  the  base  of  the  last  phalanx  which  is  affected.  The 
lips  of  the  incision  having  been  opened  up,  the  knife  is  then  carried  close  to 
bridle  along  its  whole  extent  so  as  to  separate  from  it  the  adjacent  skin,  cellular 

iii6 


DUPUYTREN  S    CONTRACTURE. 


III7 


tissue,  and  fat,  first  on  one  side  and  then  on  the  other.  In  doing  this  it  is 
necessary  to  go  some  depth  near  the  upper  end  of  the  incision,  so  as  to  divide 
the  little  bands  which  attach  the  web  of  the  finger  to  the  processes  of  fascia 
inserted  into  the  sides  of  the  first  phalanx."  Cut  across  the  tense  fascia  at  the 
digital  end  of  the  incision.  Make  further  transverse  incisions  opposite  the  mid- 
dle of  the  first  and  second  phalanges  as  may  be  required.  Divide  the  fascia 
transversely  wherever  it  seems  to  prevent  complete  extension  of  the  fingers. 
Isolated  portions  of  fascia  may  be  removed  if  convenient.  Close  the  wound  with 
sutures  after  attending  to  hemostasis.  Apply  aseptic  dressings  and  bandage 
to  a  straight  splint.  After  the  wound  has  healed,  make  use  of  massage  and 
retain  the  splint  for  two  or  three  weeks. 

Excision  of  the  Diseased  Fascia. — Complete  excision  of  the  diseased 
fascia  is  impracticable,  but  an  extensive  excision  is  both  practicable  and  bene- 


ficial. Several  methods  of  operating  have  been  devised.  Some  surgeons  ad- 
vise the  formation  of  a  V-shaped  flap  having  its  base  towards  the  fingers;  others 
advise  a  straight  longitudinal  incision  over  the  most  prominent  cicatricial  band. 
Each  method  is  proper  in  suitable  cases.  Whichever  incision  is  used,  the  scar 
tissue  is  exposed  as  completely  as  possible  by  reflecting  the  skin  in  the  manner 
described  in  Hardie's  operation.  The  cicatricial  tissue  is  divided  at  its  insertion 
into  the  phalanges,  carefully  dissected  from  the  subjacent  structures,  and  re- 
moved if  possible  in  one  piece.  Hemostasis  is  attended  to  and  the  wound 
closed.  If  the  V-shaped  incision  has  been  used,  the  flap  thus  formed  vdW 
generally  be  found  incapable  of  completely  filling  the  bed  from  which  it  was 
removed,  so  that  it  is  necessary  to  close  the  proximal  end  of  the  wound  as  if  it 
was  a  linear  incision.     The  resulting  scar  is  Y-shaped. 


mo  DUPUYTREN  S   CONTRACTURE. 

J.  D.  Griffith  excises  the  cicatricial  tissue  through  a  longitudinal  incision 
as  described  above,  but  instead  of  at  once  closing  the  wound,  he  adopts  the 
following  procedure:  From  the  end  b  (Fig.  1364)  of  the  longitudinal  incision 
A  B  he  makes  the  curved  incision  b  c  through  the  skin,  and  thus  forms  the  flap  f, 
with  its  base  a  c.  In  the  same  manner  he  makes  the  flap  e,  having  its  base  at 
B  D.  These  flaps  are  reflected  from  the  subjacent  tissues  and  turned  so  that 
the  end  of  the  flap  e  covers  the  raw  surface  left  by  the  reflection  of  the  end  of  the 
flap  F,  and  the  end  of  the  flap  f  covers  the  raw  surface  left  by  the  reflection  of  the 
end  of  the  flap  e  (Fig.  1364).  Whether  the  transposition  of  the  skin-flaps  is  of 
much  value  or  not,  the  method  has  given  good  results  in  the  hands  of  Griffith, 
and  in  one  case  in  which  the  author  used  it  the  result  seemed  excellent.  In 
most  cases,  however,  any  attempt  to  transpose  the  skin-flaps  is  unwise,  as  the 
skin  is  so  thin  and  ill-nourished  that  death  of  the  flaps  is  very  likely  to  ensue. 

Lotheissen's  Operation. — ("  Centralblatt  f.  Chir.,"  1900,  No.  20.)  Make 
the  curved  incision  a,  b,  c  (Fig.  1365).  Reflect  the  palmar  flap  thus  outlined. 
Excise  the  palmar  aponeurosis.  Extend  the  fingers.  Replace  the  flap.  With 
the  fingers  extended  there  will  be  a  small  defect  (ab)  where  the  edges  of  the 
wound  do  not  come  together.  Apply  sutures  as  shown  in  the  figure.  The 
Esmarch  bandage  is  used  to  permit  of  bloodless,  careful  dissection.  Before 
the  flap  is  replaced,  hemostasis  must  be  most  carefully  attended  to,  as  a  sub- 
cutaneous hematoma  or  the  application  of  a  compressive  dressing  endangers 
the  vitality  of  the  flap. 


INDEX. 


Abbe,  aneurysmorrhaphy,  711 

common  duct,  468 

echinococcic  cysts,  479 

Gasserian  ganglion,  72 

intestinal  anastomosis,  ^^^ 

laminectomy,  636 

oesophageal  stricture,  195 
Abdomen,  closure  of,  280 
Abdominal  ascites,  421 

nephrectomy,  540 

route,  nephrotomy,  515 

section,  277 

tuberculosis,  384 
Abscess,  651 

appendiceal,  378 

bone,  810 

breast,  235 

cerebellum,  33 

cerebral,  28 

costal  tubercular,  266 

hand,  1012 

kidney,  534 

liver,  451 

lung,  268 

Psoas,  652 

retropharyngeal,  189 

subphrenic,  453 

tubercular  abdominal,  385 
Absorbable  drains,  655 
Accessory-facial  anastomosis,  664 
Accessory  thyroids,  220 
Acetone,  catgut,  689 
Acetabulum,  exposure  of,  847 

excision  of,  848 
Acne  hypertrophica,  157 
Acromegaly,  47 
Acute  panel eatitis,  437 

peritonitis,  380 

suppurative  appendicitis,  378 
Adam's  operation,  palmar  contracture, 
1116 
saw,  835 

congenita]  dislocation  of  hip,  889 
osteotomy  hip,  865 
Adamantine  epitheliomata,  827 
Addison's  disease,  445 
Adenitis,  tubercular,  neck,  178 
Adenoma,  breast,  235,  et  seq. 

parotid,  152 
Adhesions,  gastric,  292 
intestinal,  358 
meningis  prevention,  1 1 
pericardial,  274 
Adrenalectomy,  445 


After-treatment,  arthrectomy,  hip,  857, 
860 
cleft  palate,  127,  139 
dislocation,  elbow,  994 

hip,  881 
excision,  ankle,  942 

jaw,  91 

Hp,  IIS 

rectum,  398 

tongue,  141,  143,  145 
external  urethrotomy,  594 
fracture,  olecranon,  806 

patella,  800 
frontal  sinus,  54 
gastrostomy,  296 
gastrotomy,  290 
hypospadias,  606 
internal  urethrotomy,  592 
laparotomy,  282 
laryngectomy,  201,  203 
mastoid  operation,  33 
nerve  suture,  661 
oesophagotomy,  193 
operation,     dislocation     shoulder, 

979 

piles,  417 

pneumolysis,  264 

pylorectomy,  329 

radical  cure  hernia,  497 

resection  wrist,  1004 

skin  grafting,  686 

strumectomy,  221 

tendon  suture,  1078 

tendon  transplant,  1087 

thoracoplasty,  259 
Age  for  operating  hare  lip,  117 

cleft  palate,  125 
Air  cushion,  Edebohl's,  513 

embolism,  178 

intratracheal  insufflation,  247 

liquid;  angioma,  4 

pump,  Bunsen's,  252 
Albarran,  nephropexy,  520 

prostatectomy,  585 
Albee,  arthritis  deformans,  864 
Alcohol,  injections,  neuralgia,  56 
Alexander,  sympathectomy,  188 
Alglave's  nephropexy,  522 
Alterative  operation,  nerves,  678 
Alveolar  emphysema  operation,  264 

process  resection,  90 
American  operation,  piles,  415 
Ammonium  sulphate,  catgut,  689 
Ampulla,  Vater,  473 


III9 


II20 


INDEX. 


Amputations,   1026 

arm,  1038 

Bier's,  1056 

Garden's,  1059 

cinematic,  1048 

circular,  1029 

flaps,  1032 

foot,  105 1 

fingers,  1035 

Gritt's,  1059 

Haffter's,  1057 

Hey's,  1052 

hip,  1060 

interscapular  thoracic,  1045 

interilio-abdominal,  1067 

Jordan's,  1063 

Jaboulay's,  1067 

knee,  1059 

Le  Fort's,  1055 

leg,  1034,  1055 

Lisfranc's,  105 1 

osteoplastic,  1056 

penis,  608 

Pirogoff's,  1054 

Roux's,  1054 

Sabanejeflf's,  1059 

Senn's,  1064 

shoulder,  1040 

stump,  character  of,  1028,  1029 

Syme's,  1053 

toes,  105 1 

thigh,  1060 

tumors  and  bones,  628 

wrist,  1036 
Anagmia,  splenic,  444 
Anaesthesia,  spinal,  631 
Anassthesia  in  hypophysectomy,  5 1 

local,  amputation  shoulder,  1044 
Anastomosis,  arterial,  695 

arterio  venous,  701 

intestinal,  333 

nerves,  664 

portal  V.  to  inferior  vena  cava,  424 

ureteral,  553 

vas,  617 

venous,  ascites,  424 

nerve,  anterior  poliomyelitis,   676 
Anatomy  facial  nerve,  666 

fifth  nerve,  61 

bronchus,  211 

congenital  dislocation  hip,  884 

hypoglossal  nerve,  666 

iliac  arteries,  730 

lymphatics,  scalp,  4 

of  hand,  1012 

of  kidney,  524 

peritoneal  fossas,  507 

spinal  accessory  nerve,  666 

spine,  629 

spleen,  440,  445 

thyroid,  215 

ureter,  545 

vascular  supply  lower  bowel,  407 
Anchylosis  elbow,  996 

hip,  865 

lower  jaw,  94 


Anchylosis  knee,  924 

patella  to  femur,  927 

wrist,  1006 
Andrews,  E.  W.,  colohepatopexy,    479 

Gasserian  ganglion,  67 
Aneurysm,  704 

axillary,  699 
Aneurysmorrhaphy,  709 
Anel's  operation,  706 
Angioma  scalp,  i 
Ankle,  operations  on,  936 
Annandale,    displaced    semilunar   car- 
tilage, 908 
Anterior  colostomy,  364 

gastro-enterostomy,  300 

nephrotomy,  515 
Anton,  callosal  puncture,  27 
Antrum,  Highmore,  80 

location  of,  36 

mastoid,  28 

poliomyelitis,    nerve   anastomosis, 
676 
Antyllus  operation,  706 
Anuria,  543 
Anus,  artificial,  359,  364 

gluteal,  392 

imperforate,  386 

plastic  operation,  388 

pruritus,  419 
Aorta,  resection,  700 
Apical  phthisis,  operation.,  264 
Apparatus,  direct  extension  bone,  785 

for  respiration,  247 

wry  neck,  174 
Appendicectomy   in   renal   operations, 

523 
Appendicitis,  371 

acute  suppurative,  378 

indications,  382 

tuberculous,  384 

with  abscess,  378 
Appendicostomy,  359,  363 
Arlow,  anchylosis  jaw,  94 
Arm,  amputation,  1038 

fractures,  801 

lymphangioplasty,  750 

sarcoma,  1045 
Arnd,  tetany,  217 
Arrou,  cyst  neck,  183 
Arterial  anastomosis,  695 
Arteriorrhaphy,  692 
Arterio-venous  anastomosis,  701 

aneurysm,  714 
Arteriotomy  for  embolism,  701 
Arteries,   carotid,  ligation,  hydroceph- 
alus, 40 

goitre,  ligation,  218 

ligation  of,  716 

operations  on,  692 

parathyroid,  216 
Artery,  axillary  ligation,  729 

brachial  ligation,  730 

common  carotid  ligation,  718 

carotid,  temporary  control,  183 
dangers,  ligation  of,  183 

external  carotid,  ligation,  722 


INDEX. 


II2I 


Artery,  external  iliac,  1060 

femoral  ligation,  735 

renal,  526 

resection  brachial,  700 

resection  femoral,   700 

subclavian  ligation,  727 

superior  thyroid  ligation,  725 

iliacs,  ligation,  730 

inferior  mesenteric,  4.07 
thyroid  ligation,  726 

inter  nalcarotid  ligation,  724 
iliac  ligation,  406 

lingual  ligation,  724 

mid-meningeal,  13 
Arthrectomy  elbow,  986 

hip,  856 

knee,  913 

shoulder,  926 

wrist,  1002 
Arthritis,  dry,  853 

deformans,  hip,  864 
dry  knee,  900 
knee,  919 

treatment,  1023 
Arhtritis  and  fracture,  765 
Arthrodesis,  calcaneo-cavus,  11 13 

shoulder,  978 

elbow,  991 
Arthroplasty  elbow,  996 

hip,  865 

jaw,  94 

knee,  927 

shoulder,  980 

wrist,  1006 
Arthrotomy  ankle,  936 

dislocation  shoulder,  971 

hip,  854 

knee,  901 

preliminary  injections,  900,  901 
Artificial  anus,  359,  364 

arm,  1049 

respiration,  247 
Articulation,  factors  involving,  765 

hip,  853 

transplantation  of,  781 
Ascites,  drainage,  425 

paracentesis,  424 

treatment  of,  421 

venous  anastomosis,  424 
Aspiration  liver  abscess,  451 

in  pneumothorax,  249 

knee,  900 

pericardium,  272 

pleura,  250 
Astragalus  in  club-foot,  1108,    1109 

dislocation,  943 
Astragalectomy,  1109 
Author,  aneurysmorrhaphy,  712,  713  '] 

arthroplasty  elbow,  996 

arthroplasty  wrist,  1007 

disarticulated  hip,  1066 

excision  chin  and  jaw,  113 

excision  shoulder,  964 

excision  rodent  ulcer,  87 

excision  upper  jaw,  85 

encysted  stone  in  bladder,  568 

71 


Author,  hyperpyrexia  cerebral,  23 
intracapsular  fractures,  791 
intratracheal  insufflation,  247 
prostatectomy,  5.71 
rhinoplasty,  172 
Stubenrauch's  operation,  476 
tubercular  peritonitis,  385 
bones,  775 

Axillary  aneurysm,  699 

Axhausen,  Freund's  operation,  266 

Athetosis,  operation  for,  643 

Atropin  in  obstruction,  352 

Auer,  intratracheal  insufflation,  247 

Auschiitz,  resection  liver,  449 

Auvray,  suture  liver,  449 

Babcock,  varicose  veins,  747 

Bacon,  operation  ear,  75 

Baer,  arthroplasty,  930 

Baisch,  tuberculous  peritonitis,  384 

Balch,  occlusion  external  iliac  artery, 

735 
Baldwin,  femoral  hernia,  489 
Balfour,  excision  rectum,  413 
Ball,  pruritus  ani,  419 
Ballance,  facial  palsy,  664,  666 

hydrocephalus,  39 

ligation  common  carotid  722 

spinal  puncture,  630 
Bands,  causing  obstruction,  358 
Banzet,  tendon  transplantation,  1088 
Baudet,  vasectomy,  619 
Baudouin,  hepato-enterostony,  473 

injections  neuralgia,  56,  57 
Banti's  disease,  444 
Bardenheuer  amputation   neuromata, 
1031 

anastomosis  vas,  617 

cystotomy,  567 

excision  elbow,  990 
upper  jaw,  84 

incision,  nephrotomy,  515 

plastic  cheek,  98 

resection  wrist,  1005 

sacro-iUac  disease,  850 

splenopexy,  440 

thoracoplasty,  256 
Barker,  A.  E.,  derangements  knee,  911 

bunion,  947 

excision  hip,  856,  857 

Hey's  amputation,  1052 

patellar  fract,  793 

psoas  abscess,  653 
Barnard,  H.,  amputation  in  infections, 

1027 
Barth's  operation,  54 
Bartlett,  machine,  892 

ventral  hernia,  505 
Barton,  Rhea,  osteotomy  knee,  924 

osteotomy  hip,  869 
Barwell,  congenital  dislocation  hip,  890 
Base  of  skull,  fractures,  17 
Basedow's  disease, f2 16 

sympathectomy,  188 
Bassini,  femoral  hernia,  487 

inguinal  hernia,  493 


II22 


INDEX. 


Bassini,  treatment  hernial  sac,  488 
Battle's  incision,  278,  373 

rupture  crucial  ligament,  912 
Baumgartner,  fractured  astragalus,  944 
Beck,  Carl,  decortication,  257 

empyema,  254 

epilepsy,  45 

hypospadias,  602 

meningeal  hemomata,  14 
Beck's  paste.  819,  859 
Beebe,  serum,  217 
Bell,  Jas.,  semilunar  cartilage,  911 
Belladonna,  exophthalmic  goitre,  220 
Benign  neoplasms  breast,  236 

tumors  bone,  827 
Bennet,  cerebral  topography,  18 
Berger,  interscapulo-thoracic  amputa- 
tion, 1045 

meningocele,  37 

osteotomy  hip,  873 

tendon  transplantation,  1088 

tumors  of  bone,  829 
Berg,  vicious  circle,  312 
Bergmann,  A.  von,  dislocation  hip,  879 

excision  hip,  861 

cancer  meninges,  5 

hydrocele,  625 

hyperpyrexia,  cerebral,  23 
Bergmann's  incision, nephrotomy,    514 
Bergmann,  transplantation  tendon  in- 
sertion, 1079 
Bernay's  cholecystotomy,  459 
Berndt,  excision  lower  jaw,  92 
Berry,  enucleation  goitre,  231 

goitre,  228 
Bevan's  incision,  455 
Bevan,  transfusion,  739 

undescended  testes,  622 
Beyea,  gastropexy,  297 
Bier,  abscess,  652 
Bier's  cup,  mastoiditis,  37 
Bier,  infections  hand,  1015 

osteoplastic  amputation,  1056 
Biliary  passages,  operation  on,  454 
Billroth,  cleft  palate,  137 

excision  tongue,  142 

forceps,  693 

oesophageal  stricture,  195 
Bindi,  omentopexy,  423 
Bird,   Golding,   sacro-iliac   disease,  850 
Birth,  palsy,  669 
Bismuth  paste,  819,  859 
Bladder,  gall,  456 

perineal  operations,  582 

repair  of,  575 

rupture,  563 

tumors,  568 

urinary,  herniotomy,  483 
operation  on,   557 
Blair,  V.  P.,  lower  jaw,  94 
Blake,  J.  A.,  peritonitis,  381 
Blasius   lower  !ip,  115 
Bleeding  after  intestinal  suture,  286 
Bleeding  from  veins,  737 
Bleeding,  liver,  449 

subdural.     Gushing,  25 


Block,  J.,  Bottini  operation,  581 
Blocking  nerves,  1044,  1047 
Blood  supply,  rectum,  407,  412 

transfusion,  739 

vessels,  surgery  of,  692 
Bloodgood,  hernia,  498 

tumors,  bone,  827 
Bodies,  foreign,  in  oesophagus,  192 

foreign,  trachea,  210 

loose  in  knee,  907 
Boekman,  formalin  catgut,  691 
Bogoljuboff,  anastomosis  vas,  621 
Bond,  echinococcic  cysts,  480 
Bone  chips,  decalcified,  818 

cavities,  obliteration  of,  815 

decalcified,  tubes,  656 

forceps,  755 

infections,  810 

inplantation,  764 

intermaxillary,  harelip,  123,  131 

methods  of  fixation,  770 

operation  for  fractures,  754 

plastic  operation,  820 

plugs,  815 

skull  reimplantation,  7 

transplantation,  780 

tumors  of,  827 
Bones,  pelvic,  846 
Bougies,  oesophageal,  193 

rectal,  390 
Bothezat,  arthrodesis  shoulder,  978 
Bottini,  prostatotomy,  579 
Boutonniere  operation,  582 
Bouvier,    congenital    dislocation     hip, 

890 
Bowels,  obstruction,  351 
Bow  leg,  843 
Brachial  artery  ligation,  730 

plexus,  sarcoma,  1045 

palsy,  669 

resection,  700 
Bradford,    congenital   dislocation    hip, 

889 
Brain,  decompression,  24 

infections,  28 

skull  fracture,  15 

tumors,  18 
Bramann,  callosal  puncture,  27 

Freund's  operation,  265 

hydrocephalus,  40 
Branchial  fistu'ae,  184 
Brasdor's  operation,  706 
Brauer,  preumolysis,  260 

cardiolysis,  275 
Brauer's  cabinet,  247 
Braun's  neurectomy,  64 

peptic  ulcer,  314 

resection  aorta,  700 

salivary  fistula,  156 

thread,  687 
Breast,  operations  on,  235 
Brenner,  fiat  foot,  1069 
Brentano,  cholecystenterostomy,  466 
Brewer,  artery  suture,  694 

diverticulitis,  349 

Gasserian  ganglion,  71 


INDEX. 


112 


Brewitt,  late  results  fracture  skull,  15 
Brieau-Jaboulay,    artery    suture,    694, 

697 
Broca,  hyperpyrexia,  cerebral,  23 
Bronchocele,  215 
Bronchotomy,  211 

in  tracheal  stenosis,  214 
Bronchiectasis,  268 
Bronchus,  foreign  bodies  in,  210 
Brodhurst,  congenital  dislocation  hip, 

890 
Broedel,  anatomy  kidney,  532 
Brophy,  cleft  palate,  125 

tension  sutures,  139 
Brown,  congenital  dislocation  hip,  889 
Bruns,  lower  lip,  114 

neurorrhaphy,  659 

wry  neck,  175 
Brunner,  pylorectomy,  326 
Briinig,  cardiospasm,  290 
Bryant,  angioma  scalp,  2 

bronchotomy,  212 

colostomy,  360 
Bryant,  Thomas,  Dix's  operation,  707 

tracheotomy,  206 
Buchman,  transplantation  joints,  999 
Buck,  anchylosis  knee,  924 
Bull,  oesophagotomy,  192 
BuUard,  pachymeningitis,  47 
Bull,  sliding  hernias,  487 
Bullet  wounds  spine,  640 
Bunge,  amputations,  1030 

dislocation  elbow,  993 
Biinger,  v.,  excision   symphysis   pubis, 
848 

union  bones,  773 

vasectomy,  619 
Bunion,  947 
Bunsen's  air  pump,  252 
Burghard,  thoracoplasty,  257 

dislocation  hip,   880,   882 
shoulder,  970 

excision  scapula,  959 

fracture  humerus,  802 

fracture  os  calcis,  801 
Burow,  lower  lip,  115 
Burrell,  dislocation  shoulder,  979 

spinal  injuries,  641 
Bursas  hand,  1012 
Bursitis,  Codman's,  985 

hallux  valgus,  947 
Busch,  retropharngeal  tumor,  190 
Butlin,  amputation  penis,  609 

excision  tongue,  145 

preliminary  laryngotomy,  145 

statistics  excision  tongtie,  147 
Button,  Murphy,  336,  341,  314 

Cabinet,  differential  pressure,  247 
Cachexia  strumipriva;  transplantation 

thyroid,  231 
Cackovic  vicious  circle,  312 
Caecectomy,  346 
Caecum,  excision,  346 
tuberculosis,  384 
Cahier,  diverticulitis,  349 


Calcaneum,  operation  on,  945 

fracture,  801 
Calcium  chloride  in  jaundice,  432,  454 
Calculi,  biliary,  460 

common  duct,  467 

in  bladder,  567 

in  cystic  duct,  466 

in  ureter,  549 

pancreatic,  438 

renal,  535 
Callosal  puncture,  27 
Callus,  excessive,  783 
Cancer,  bladder,  569 

breast,  236 

cheek  and  jaw,  100 

chest,  267 

larynx,  199,  et  seq. 

neck,  182 

parotid,  152 

penis,  609 

prostate,  587 

pylorus,  320 

rectum,  391,  et.  seq. 

scalp,  4 

stomach,  results,  329 

testes,  615 

tongue,  see  tongue, 

transfusion,  739 
Cannula,  Hepburus,  742 

laryngotomy,  197 

tracheotomy,  207 

transfusion,  739,  741 
Cantwell,  epispadias,  598 
Capsule,  thyroid,  215 
Capsulorrhaphy,  shoulder,  97 g 
Caput  obstipum,  174 
Carcinoma  bone,  830 

breast,  236 

chest,  267 

renal,  538 

stomach,  320 

tongue,  see  tongue 
Carbolic  injection  hydrocele,  O25 
Carden's  ainputation,  1059 
Cardiac  operations,  273 
Cardiolysis,  274 
Cardiospasm,  290 
Cargile's  membrane,  47,  358 
knee,  930 
nerve  sutiire,  661 
Carnes,  artificial  arm,  1049 
Carotid     artery,     temporarv     control, 
182 

common  ligation,  718 

internal  ligation,  724 

external  ligation,  84,  85,  722 
Carpal  bones,  removal  of,  1002 
Carrel,  artery  suture,  692,  et.  seq. 

intratracheal  insufflation,  247 
Cartilage  costal,  typhoid,  267 

knee  displaced,  908 
Carwardine,  parotid  operation,  152 
Castration,  615 
Catgut,  688 

Catheterization,  retrograde,  594 
Catterina  excision  shoulder,  968 


II24 


INDEX. 


Cauda  equina  injuries,  640 
Cautery,  abscess  lung,  269 

Cautery  and  clamp  piles,  417 
Cavernous  sinus,  wounds,  70 
Cavicchia,  laminectomy,  636 
Cavities  bone,  obliteration,  815 
Cecca,  varicose  veins,  745 
Cerebral  abscess,  28 

decompression,  25 

pressure,  relief  of,  24 

symptons    after   carotid   ligation, 
721 

tumors,  18 

ventricles,  drainage,  39 
Cerebellar  abscess,  ^^ 
Cerebellum  decompression,  25 
Cerebro-spinal     fluid,     hydrocephalus, 

38 
Celiotomy,  277 
Celluloid  hemp,  285,  687 

in  trephining,  1 1 
Centers,  motor,  18 

thermo-taxic,  23 
Cervical  sympathetic  185 

oesophagotomy,  192 

nerves,  division  of,  176 

tumors,  178 
Chassaignac,  tendon  suture,   1078 
Chase,  spinal  injuries,  640 
Cheek,  excision,  97 
Chest,  operation  on,  246 
Chetwood,  prostatotomy,  580 
Chevriers  incision,  277 
Chewing-gum,  hemostasis,  7 
Cheyne,   costal  tuberculous,   266 

dislocation  hip,  880,  882 
shoulder,  970 

epispadias,  598 

fracture  humerus,  802 
OS  calcis,  801 

thoracoplasty,  257 
Chiene,  knock  knee,  840 

cerebral  topography,  19 

retropharyngeal  abscess,  189 
Chin  and  jaw,  excision,  113 
Chipault,  meningocele,  3  7 

spinal  anatomy,  629 
injuries,  640 
Chisel,  opening  skull,  9 
Chisels,  832 

for  mastoid  operation,  34 
Choice  of  operation  piles,  418 

gall  stones,  477 
Cholangi ostomy,  473 
Cholecystectomy,  459,  462,  465 
Cholecystenterostomy,  465 

in  pancreatitis,  438 
Cholecystostomy,  459 

in  pancreatitis,  438 
Cholecystotomy,  456 
Choledochotomy,  467 
Chondrectomy,  83  i 
Chondroma  pelvis,  846 
Chromicized  catgut,  691 
Chronic  pancreatitis,  438 
Cinematic  amputations,  1048 


Circular  amputations,  1029  j 

arteriorrhaphy,  695 

enterorrhaphy,  338 
Circumcision,  613 
Cirsoid  aneurysm,  704 

angioma  scalp,  2 
Clairmont  angioma,  2 
Clamp  and  cautery,  piles,  417 
Clamps,  artery  suture,  693 

external  bone,  772 

gastro-enterostomy,  307 

intestinal,  283 

pile,  417 
Clarke,   W.,   lymphangioplasty,    753 
Claudius,  catgut,  689 
Clavicle,  dislocation  of,  961 

excision,  959 

operations  on,  952 
Claviculo-humeral  nearthrosis,  982 
Clay,  nephro-lithiasis,  537 
Cleft  palate,  125 

Clogg,  perforation  duodenum,  331 
Closure,  abdomen,  280 

bladder  wound,  566 

chest  defect,  268 

defects  in  dura,  16 

dural  defects,  46 

facial  fistula,  364 

intestinal  wounds,  331 

skull  defects,  1 1 

wounds  pelvis  kidney,  536 
Clubbe,  intussusception,  357 
Club  foot,  1 102 

paralytic,  1088 

shoe,  1 1 12, 
Clutton,  endosteal  sarcoma  828 
Cocaine,  amputation  shoulder,  1044 

exophthalmic  goitre,  220 
Codivilla,  autoplasty,  780 

direct  extension  bone,  785 
Codman's  bursitis,  985 

implantation  bone,  777 
Coecostomy,  362 
Coffey,  intussusception,  354 
Colectomy,  348 
Coley,  sliding  herniae,  487 
Colles's  fracture  malunion,  785 
Collier,  sacro-iliac  disease,  850 
CoUis,  hare  lip,  119 
Collin's  osteoclast,  845 
Colohepatopexy,  479 
Coloboma  ear,  74 
Colon,  idiopathic  dilatation,  349 

pelvic,  blood  supply,  407,  412 

ptosis,  nephropexy,  521 
Colopexy,  389 
Colo-rectostomy,  391 
Colostomy,  359 

preliminary,  404 

rectal  stricture,  391 
Combined  abdominal  and  perineal  rec- 

tectomy,  406 
Common  carotid  artery  ligation,  718 

duct  incision,  467 

femoral  artery  ligation,  735 

iliac  artery  ligation,  734 


INDEX. 


II25 


Complications,    internal    urethrotomy, 

591 
Compound  fractures,  763 
Compression  spinal  cord,  638,  639 
Condyles  femur  fracture,  793 

humerus  fracture,  803 

jaw  excision,  94 
Congenital  absence  tibia,  780 

club-foot,  1 102 

dislocation  hip,  883 
knee,  920 
patella,  934 

fistula  neck,  184 

obstruction  pylorus,  317 
Connell's  suture,  342 
Connor,  gastrectomy,  299 
Conservative  operation,   bone  tumors, 

828 
Contraindications  vSplenectomy,  443 
Contracture,  Dupuytren's,  11 16 
Contractures  in  pseudarthrosis,  766 
Coolidge,    congenital    dislocation    hip, 

890 
Cooper,  common  duct,  468 

ligation  external  iliac  artery,  734 
Cord,  hydrocele  of,  626 

spinal,  injuries,  639 
tumors,  638 
Coronoid  process  ulna  fracture,  805 
Corpus  callosum,  puncture,  27. 
Corson,  omentopexy,  424 
Costal  cartilage,  rhinoplasty,  164,  172 

tuberculosis,  266 
Coxa  vara,  865,  875 
Coxitis,  remarks,  863 
Cramer,  anchylosis  patella,  927 
Cranium,  decompression,  24 
Cranial  contents,  infection,  28 

defects,  closure  of,  1 1 

fractures,  15 
Craniectomy,  microcephalus,  38 
Cranwell,  diaphragm,  hernia,  511 
Creaking  knee,  Jones.  R.,  920 
Crede,  amputations,  3031 

rectal  stricture,  390 
Crile,  amputation  shoulder,  1044 

excision  of  tongue,  148 

exophthalmic  goitre,  219 

Gasserian  ganglion,  72 

intubation,  excision  tongue,  145 

nerve  block,  1044,  1047 

occlusion  common  carotid,  722 

transfusion,  739 

treatment      after       strumectomy, 
222 

tumors  neck,  183 

vagus  section,  183 
Criles'  artery  clamp,  693 

cannula,  741 
Cripps'  incision,  360 
Croft,  dislocation  ulnar  nerve,  677 

plastic  surgery,  682 
Crucial  ligaments,  rupture,  912 
Cullen,  cancer  liver,  449 

nephrotomy,  532 
Cumston,  castration,  616 


Cuneiform  osteotomy,  83  7 

hip,  875 
Curtis,  sympathectomy,  188 
Cushing,  cerebrospinal  drainage,  41 

decompressive  operations,  24 

facial  palsy,  664 

fracture  skull,  17 

Gasserian  ganglion,  71 

hypophysectomy,  52 
Cushing's  suture,  288 
Cushion,  Edebohl's,  513 
Cyst,  cerebral,  23 

echinococcic  abdomen,  479 
lung,  268 

hypophysis,  48 
Cysts  of  bone,  827 

pancreas,  430 

sebaceous,  i 

spleen,  442 

thyroglossal,  184 
Cystic  lymphangioma,  183 
Cystectomy,  571 
Cysticotomy,  466 
C}'^stotomy,  infrapubic,  589 

perineal,  582 

suprapubic,  564 
Czerny,  gastro-enterostomy,  313 

DaCosta,  ligation  common  carotid,  721 

prostatotomy,  579 
Dahlgren,  obstruction,  352 
Dangers  Bottini  operation,  581 

internal  urethrotomy,  591 

ligation  common  carotid,  721 
femoral  artery,  735 

transfusion  blood,  741 
Davidson,  W.,  transplantation  parathy- 
roid, 232 
Davis,  G.  G.,  anchylosis  knee,  927 

choledochotomy,  469 

congenital     dislocation    hip,     883, 
892 

Incision,  373 

paralytic  eversion  leg,  1099 
Davison,  closure  abdomen,  281 
Dawbarn,  appendicectomy,  376 

malunion  Colles's  fracture,  787 
Dead  bone,  treatment,  817 
Decalcified  bone  chips,  782,  8i8 

bone  drains,  656 

bone  ferrules,  772 
Decompression,  fracture  skull,  17 
Decompressive  operation,  24 
Decortication  kidney,  534,  543 

pulmonary,  257 
Defects  chest  wall,  268 

dura,  46 

in  cheek,  98 

in  dura,  closure  of,  16 

in  skull,  closure  of,  1 1 
Deformities  ear,  72 

hip,  865 
Deformity  after  excision  lower  jaw,  91 

after  fracture,  783 
thoracoplasty,  259 

lower  jaw,  94 


1 126 


INDEX. 


DeFourmestraux,      ligature     common 

carotid,  721 
DeFrancesco,  amputation,  1049 
Deguise,  salivary  fistula,  155 
Delageniere,  pneumothorax,  268 

omentopexy,  424 

cysticotomy,  467 
Delbet,  excision  rectum,  392 

exploration  kidney,  530 

obstruction,  351 

pyelotomy,  536 

renal  pelvis,  525 

ureterotomy,  550 
Delormc,  cardiolysis,  275 

decortication,  257,  258 

thoracoplasty,  257 
Deltoid  paralysis,  674,  955 
Denker's  operation,  157 
Dennis,  thoracocentesis,  250 
Dentigerous  cysts,  827 
Depage,   empyema,  259 

hepatopexy,  447 
Depressed  fracture  skull,  15 
Derge,  nephrotomy,  532 
Deruginsky,  tumors  chest,  267 
Deschamp's  needle,  138 
Desjardins,  excision  pancreas,  434,  435 
Desmarest,  sarcoma,  hip,  1066 
DeSouza,  sympathactomy,  188 
DeVerco,  hyperpyrexia  cerebral,  23 
DeVilbiss'  forceps,  10 
Diabetes,  pancreatic,  433 
Diagnosis  rupture  bladder,  563 
Diakonow,  anchylosis  elbow,  999 
Diaphragmatic  hernia,  510 
Didot,  syndactylism,  1009 
Diefifenbach,  dislocation  shoulder,   970 

excision  rectum,  393 

lower  lip,  1 14 

partial  excision  tongue,  140 

rhinoplasty,  159 
Diet,  pancreatic  traumata,  439 
Differential  pressure  cabinet,  247 
Dilatation,  idiopathic,  colon,  349 

rectal  stricture,  390 
Direct  extension  bones,  785 
Disassociation  nerve  fibres,  678 
Disarticulation,  1026 

elbow,  1038 

foot,  105 1 

fingers,  1035 

hip,  1060 

Jordan's,  1063 

knee,  1059 

Lisfranc's,  105 1 

Senn's  1064 

shoulder,  1040 

toes,  105 1 

wrist,  1036 

Wyeth's,  1064 

Diseases  adrenals,  445 
Dislocation,  astragalus,  943 
Disease,  Banti's,  444 

Basedow's,  216 

GraA'es',  216 


Disease,  Hirschsprung's,  349 

malignant,  intranasal,  157 

Milroy's,  753 
Dislocation,  clavicle,  961 

elbow,  993 

fingers,  1008 

habitual  shoulder,  979 

hip,  879 

congenital,  883 
with  fracture,  882 

knee,  congenital,  920 

patella,  933 

shoulder,  969 

tendon  peroneias  longus,  1080 

ulnar  nerve,  677 
Displaced  semilunar  cartilage,  908 
Dittel,  v.,  amputation  penis,  612 
Diverticula,  oesophageal,  193 
Diverticulitis,  349 
Diverticulum  vesical,  568 
Division  posterior  nerve  roots,  643 
Dix's  operation,  707 
Doberauer,  embolism,  701 
Dobson,  csecectomy,  346 
Dollinger,   dislocation  shoulder,   972 

pneumo-thorax,  268 

tuberculous  glands,  neck,  181 
Dorrance,  transfusion,  743 

artery  suture,  692,  et  seq. 
Dowd,    fracture    dislocation    shoulder, 

977 
Dowd's  operation,  106 
Doyen,  intestinal  clamp,  285,  307 
Doyen's  perforator,  10 
Drainage  abdomen,  281 

abscess,  651 
lung,  268,  269 

after  choledochotomy,  467 
nephrotomy,  533 
pylorectomy,  327 
trephining,  13 

appendiceal  abscess,  379 

antrum  highmore,  80 

bladder  583,  566 

bronchial  phlegmon,  213 

cerebral  abscess,  32 

cystic  duct,  466 

duodenal  ulcer,  331 

echinococcic  cysts,  480 

frontal  sinus,  53 

gall-bladder,  460 

hand,  1012,  et  seq. 

hepatic  duct,  467,  472 

hip,  85s 

hydrocele  neck,  183 

hydrocephalus,  38 

knee,  901 

mediastinum,  276 

methods  of,  654 

of  ankle,  936 

osteomyelitis,  813 

pancreatic  cyst,  434 

perforation  stomach,  291 

peritonitis,  381 

permanent  ascites,  425 

pleura,  251 


INDEX. 


II27 


Drainage,  retropharyngeal  abscess,  189 

spinal  meningitis,  632 

in  syringomyelia,  643 

ureter,  552 
Dressings,  hare-lip,  123 

laparotomy,  282  .. 
mastoid  operation,  31 
skin  graft,  686 
Drummond  omentopexy,  422 
Dry  arthritis,  1025 

knee,  900 
Duchenne-Erb  paralysis,  669 
Ducts,  bile,  exposure  of,  455 

common,  incision,  467 

cystic,  466 

Steno's,  fistula,  154 

thoracic  injury,  179 

thyroglossal,  184 
Dumstrey,  nerve  suture,  662 
Duodenal  ulcers,  291,  331 

auto-intoxication,  313 
Duodeno-choledochotomy,  472 

-jejunal  hernia,  517 
junction,  305 
Duodenum,  mobilization  of,  319 
Duplay,  hypospadias,  603 
Dupuytren,  causation  emphysema,  264 

closure  faecal  fistula,  365 

congenital  dislocation  hip,  889 
Dupuytren's  contracture,  11 16 

suture,  286 
Dura,  cancer  of,  5 

defects,  closure  of,  16 

separator,  10 

wounds  of,  13 
Dural  defects,  46 
Durante,  laminectomy,  636 

plastic  operation  anus,  388 
Duret,  gastropexy,  279 
Duval,  scapula  alata,  952 

iliac  arteries,   730 

inesosigm.oiditis,  358 

vasectomy,  619 
Dwight,  intermetatarseum,  947 
Dyspnoea,  cardiolysis,  273 


Ear,  infection  of,  28 

Eck's  fistula,  424 

Echinococcic  cysts,  abdomen,  479 

lung,  268 
Ectopia  vesicae,  557 
Edebohls,  decortication,  534,  543 

nephropexy,  5 1 9 
Edebohls'  posture,  513 
Effusion  pericardmm,  272 
Effusions,  pheural,  250 
Egg  membrane  in  trephining,  1 1 
Ehrhardt,  excision  thymus,  233 
Eiselerg,  v.,  amputation  for  gangrene, 
1027 

exploration  kidney,  516 

hypophysectomy,  48 

osteoplasty,  825 

scapula  alata,  952 


Elastic  constrictor,  scalp,  6 
ligature,  312,  314,  337 
liver,  449 
Elbow  anchylosis,  996 
arthrodesis,  978 
disarticulation,  1038 
dislocation,  993 
fractures,  803 
joint  operations  on,  986 
transplantation  joint,  999 
Electric  saw,  10 
Elephantiasis,  753 
Elliot,  choledochotomy,  469 
EUot,  Ellsworth,  aneurysm,  708 

intussusception,  355 
Elsberg,  catgut,  689 
empyema,  253 
insufflation  air,  247 
Mosetig's  plugs,  815 
wounds  pleura,  246 
Emasculation,  609 
Embolism  air,  178 

operation,  treatment,  700 
Emphysema  after  pneumolysis,  264 

alveolar  operation,  264 
Empyema  antrum  Highmore,  80 
fracture  rib,  250 
frontal  sinus,  53 
knee,  900 
thoracic,  251 
double,  259 
Encephalocele  operation,  37 
Enchondroma  parotid,  153 
Enchondromata,  827 
Enderlen  excision,  popliteal  aneurysm, 

708 
Endlich,  dislocation  hip,  881 
Endo-aneurysmorrhaphy,  709 
Enterectomy,  345 
Enterorrhaphy,  338 
Enterostomy,  353,  359 
Enterotomy,  331 
Enucleation  goitre,  230 

tumors  parotid,  152 
Epididymectomy,  616 
Epididymis  tuberculous,  620 
Epiglottis  tumors,  197 
Epilepsy  after  fracture  skull,  1 5 
operation  for,  43 
prevention  adhesions,  1 1 
sympathectomy,  188 
Epiphysis  femur,  separation,  787 
humerus,  separation,  802 
separation  femoris,  792 
Epiplopexy,  422 
Epispadias,  598 
EpitheUoma  bladder,  569 
cheek  and  jaw,  100 
Hp,  103 
scalp,  4 

tongue,  see  tongue. 
Epitheliomata,  adamantine,  827 
Erb  paralysis,  669 
Eremitsch  pharyngotomy,  197 
Esmarch  excision  rectum,  405 

indications  amputations,  102O 


II28 


INDEX. 


Esmarch  sylvian  fissure,  18 

Estes,  amputations  for  injury,  1027 

disartic  elbow,  1039 
Estlander's  operation,  256 

lower  lip,  1 14 
Etiology  congenital  dislocation  hip,  883 
Evacuation  goitre,  231 

hydrocele  neck,  183 
Evans,  parathyroids,  216 
Eve,  P.,  gastropexy,  297 
Evulsion  nerves,  61 
Exopexy  thymus,  233 
Exophthalmic  goitre,  215,  216,  218 
Exophthalmos,  ligature  common  caro- 
tid, 722 
Exostosis  pelvic  bones,  847 

OS  calcis,  945 
Examination  bile  passages,  456 
Exarticulation  tumors  bone,  828 
Excision  acetabulum,  848 

adrenals,  445 

aneurysm,  708 

wens,  I 

angioma  scalp,  i 

ankle,  937 

astragalus,  1 109 

bladder,  571 

breast,  236 

cancer  cheek  and  jaw,  100 
scalp  and  skull,  5 

cervical  sympathetic,  185 
tumors,  1  78 

cheek,  97 

clavicle,  959 

colon,  348 

elbow,  986 

fistula  in  ano,  421 

fistulas  neck,  184 

gall-bladder,  462 

Gasserian  ganglion,  67 

gastric  and  duodenal  ulcers,  291 

hepatic  tumors,  448 

hip,  856 

hydrocele,  625 

intranasal  malignant  tumors,  157 

kidney,  538 

knee,  913 

lip,  103 

lung,  259,  268 

palmar  fascia,  11 17 

pancreas,  434,  435 

parotid  tumors,  152 

patella,  923 

pelvic  bones,  846 

piles,  416 

pituitary  body,  47 

prolapsus  recti,  389 

prostate  cancer,  587 

pylorus,  320 

rectal  stricture,  391 

rectum,  391 

retropharyngeal  tumor,  igo 

sacro-iliac  joint,  850 

scapula,  956 

seminal  vesicles,  620 

semilunar  cartilage,  908 


Excision  shoulder,  962  et  seq. 

sigmoid,  348 

small  intestine,  345 

spleen,  441 

stomach,  298 

sterno-mastoid,  174 

symphysis  pubes,  848 

testes,  615 

tongue,  140 

thymus,  233 

thyroid,  221, 

tumors,  chest  wall,  267 

tuberculous  rib,  266 

tumors  bone,  827 
bladder,  568 
orbit,  81 

ulcer  stomach,  298 

upper  jaw,  83 

urethral  stricture,  594 

varicose  venis,  746 

vas  deferens,  618 

wrist,  1002 
Exclusion,  intestinal,  349,  369,  385 
Exploration  abscess  lung,  269 

bladder,  564 

gall-bladder,  etc.,  456 

kidney,  526 

pericardium,  272 

pleura,  250 

renal  pelvis,  524 

stomach,  289 

ureter,  550 

vertebral  canal,  634 
Exposure,  base  of  skull,  89 

hip,  853 

kidney,  513 

musculo-spiral  nerve,  680 

pericardium,  273 

skull,  6 

ureter,  549 
Exstrophy  bladder,  557 
Extension,  direct  to  bone,  785 

in  pseudarthrosis,  766 
External  clamps,  bone,  772 

carotid,  ligation,  84,  85,  722 

ear,  plastic  operation,  72 

iliac  artery,  734 

piles,  416 

popliteal  nerve,  stretching,  679 

urethrotomy,  592 
Extirpation  hydrocele  neck,  183 
Extravasation  urine,  595 
Eyelids,  oedema,  753 

Faecal  fistula,  closure,  364 
Facial  nerve,  in  mastoid  operation,  30 
operation  on  parotid,  152 
stretching,  680 
suture,  658 
palsy,  664 

spasm,  injections,  60 
Fallopian  tubes,  tuberculosis,  384 
False  aneurysm,  704 
Farabeuf,  disartic  elbow,  1040 
ligation  art,  717 
ligation  axillary  artery  729 


INDEX. 


II29 


Fabrique,  appendicectomy,  377 
Fascia,  palmar,  contracture,  1116 
for  closure,  dural  defects,  47 
Fascial  transplantation  hernia,  501,  505 
Fasciotomy,  plantar,  iioi 
Fauntleroy,  transfusion,  743 
Faure,  facial  palsy,  664 
Federoff,  pharyngotomy,  197 
Feeding  after  laryngectomy,  201,  203 
Feiss,  Pott's  tract,  788 
Femoral  artery  ligation,  735 
resection,  700 
epiphysis,  separation,  787,  792 
hernia,  487 
Femur,  condyles  fracture,  793 
fractures,  head  of,  789 
sarcoma,  1066 
Fenger,  hydronephrosis,  548 
meningocele,  38 
urethral  stricture,  552 
Fenwick,  encysted  calculus,  568 
Ferguson,  A.  H.,  cerebro-spinal    drain- 
age, 41 
decortication,  534,  543 
excision  upper  jaw,  84 
inguinal  hernia,  495 
tractor,  584 
Ferrules,  bone,  772 
Fever,  urethral,  592 
Fiaschi,  sliding  hemiae,  487 
Fick,  relative  strength  muscles,  1091 
Fifth  nerve,  neurectomy,  61 
Fingers,  amputation,  1035 
dislocation,  1008 
in  rhinoplasty,  170 
trigger,  loio 
Fingers,  webbed,  1009 
Finney,  gall-stone  scoop,  459 
Finney's  pyloroplasty,  317 

rhinoplasty,  170 
Finsterer,  dural  defects,  46 
Fischer,  injections  neuralgia,  60 
Fissured  fracture  skull,  1 6 
Fissure  of  Rolando,  location,  18 
Fistula,  congenital  neck,  184 
fsecal  closure,  364 
in  ano,  420 
Fistulae,  pancreatic,  434 
Fistula  sahvary,  154 
Fistulae  hip,  863 

congenital  neck,  184 
Fixation  bones,  770 

kidney,  516 
Flail  shoulder,  978 
Flaps,  amputation  by,  1032 
Flat-foot,  1069 
Flint,  bone  pegs,  761 

wounds  knee,  905 
Floating  bodies  in  knee,  907 
kidney,  516 
liver,  446 
spleen,  440 
Floor  of  mouth,  cancer,  148 
Fluid,  Murphy's  900 

van  Arsdales,  398 
Flushing  peritoneum,  380 


Focal  epilepsy,  45 
Foderl,  laryngectomy,  203 
Foerster's  operation,  643 
Foot,  amputation,  105 1 
Foot,  club,  1 102 
flat,  1069 
hollow,  1113   , 
Foramen  ovale,  injection  at,  58 
rotundum,  injection  at,  59 
Foramitti,  neurorrhaphy,  659 
Forceps,  De  Vilbiss',  10 
Keen's,  9 
Lane's,  755 

Rongeur,  for  mastoid,  35 
Thomas's,  1060,  1061 
Forcipressure  737 

Forcible  rectification,  club-foot,  1103 
Forearm,  amputation,  1038 
Foreign  body  larynx,  198 
bodies  in  intestine,  331 
in  oesophagus,  192 
in  thoracic  oesophagus,  276 
in  trachea  or  bronchus,  210 
Formalin  glycerine,  652,  900 

gelatine  plug,  921 
Formalinized  catgut,  691 
Fossae,    nasopharynx;    retromaxilliary ; 
pterygo-palatine,  157 
peritoneal,  507 
Fowler,  decortication,  257 
Gasserian  ganglion,  72 
knock-knee,  840 
occlusion  common  carotid,  722 
peritonitis,  381 
vicious  circle,  312 
Fowler's  position,  331 
Fracture  calcaneum,  801 
coronoid  process,  808 
dislocation  hip,  882 
dislocation  shoulder,  977 
elbow,  803 
head  radius,  809 
humerus,  801 
involving  joint,  765 
olecranon,  806 
simple,  operation,  754 
skull,  late  results,  1 5 
special,  789 
spine,  639 
tubercle  tibia,  800 
Fractures  base  skull,  Cushing's  opera- 
tion, 25 
compound,  763 
malunion,  783 
of  skull,  15 
ununited,  766 
Franck  O.,  tracheotomy,  207 
Frank,  gastrostomy,  293 
rupture  kindey,  541 
Frankes'  operation  orbit,  81 
Frazier  facial  palsy,  666 

decompressive  operation,  25 
Foerster's  operation,  644 
laminectomy,  634 
Freeman's  apparatus,  761,  772 
bone  clamps,  772 


II30 


INDEX. 


Freeman's  excision  liver,  449 

hemostasis  skull,  7 

semilunar  cartilage,  908 

Treitz  hernia,  507 
Freezing,  angioma,  4 
French  method  rhinoplasty,  113 
Freudenthal,  frontal  sinus,  54 
Freund's  operation  phthisis,  264 
Freyer,  prostatectomy,  571 
Frick,  W.  J.,  aneurysmorrhaphy,  713 
Friedel  varicose  veins,  748 
Friedrich,  antrum  Highmore,  81 

epilepsy,  44 

Freund's  operation,  265 

oesophagotomy,  192 

operation,  thorax,  253 

pneumolysis,  260 
Fright,  exophthalmic  goitre,  220 
Frommer,  osteoplastic  amputation, 

1056 
Frontal  nerve,  61 

sinus,  53 
Puller,  microcephalus,  38 
Fusiform  aneurysm,  704 

Gags,  mouth,  127,  136 
Gag,  whitehead's,  141 
Gall-stones,  460 

indications,  477 
Gall-bladder,  operations  on,  456 
Gait  trephine,  7 

Galvano-caustic  prostatotomy,  579 
Ganglion,  Gasserian,  67 
Gangrene,  arterio-venous  anastomosis, 
701 

in  hernia,  484 

intestine,  345,  358 

lung,  268 

when  to  amputate,  1026 
Gant's  clamp,  417 

osteotomy  hip,  871 
Gardner,  wry  neck,  175 
Garre,  colopexy,  389 

resection  liver,  450 
Gasserian  ganglion,  67 
Gastrectomy,  297 

and  pylorectomy,  320 
Gastric  operations,  289 

ulcer,  290 
Gastrotomy,  289 

bodies  in  oesophagus,  192 
Gastro-enterostomy,  feeding  after,  290 
Gastrolysis,  292 
Gastrostomy,  292 
Gastroplication,  296 
Gastropexy,  296 
Gastro-enterostomy,  300 
Gehle,  oesophageal  diverticulum,  194 
Gelatine  plug,  Murphy,  921 
Gely's  suture,  287 
General  peritonitis,  380 
Genito-urinary  system,  513 
Genu  recurvatum,  932 

valgum,  839 

varum,  843 
Gersuny,  gluteal  anus,  393 


Gibbon,  ureterotomy,  549 
Gibney,  tendon  shortening,  1092 
Gigli  saw,  835 
skull,  10 
Ginsburg,  transfusion,  743 
Giordano,  vagus  section,  183 
Giraldes,  hare  lip,  121 
Girard,  mastopexy,  235 

oesophageal  diverticula,  194 
Glade,  tumor  pancreas,  434 
Glands,  cancer  tongue,  142,   143,   144, 
146,  148 
lymphatic  caecum,  347 
lip,  103 

penile,  609 
scalp,  4 
parathyroids,  215 
parotid,  operation  on,  152 
thyroid,  215 
thymus,  233 
tuberculous  neck,  178 
lymph  stomach,  320,  326 
lymphatic  testes,  616 
Glaucoma,  sympathectomy,  188 
Gleich,  flat  foot,  1069 
Gliick,  bronchotomy,  213,  214 
cavities,  lung,  268 
laryngectomy,  202 
nerve  grafting,  659 
preumectomy,  271 
thoracoplasty,  259 
Gluteal  anuerysm,  711 

anus,  392 
Glycerine  iodoform  and  formalin,  900 
Glycosuria  pancreatic,  433 
Goitre,  215 

sympathectomy,  188 
trachei  tomy  in,  207 
Gold  foil,  trephining,  1 1 
Goldthwaite,   habitual  dislocation  pa- 
tella, 934 
Gonorrheal  arthritis,  1025 
Goodman,  Freund's  operation,  265 
Gottstein,  Foerster's  operation,  645 
Gouges,  832 
Gould,  amputation  penis,  608 

appendicectomy,  377 
Gould's  mattress  suture,  286 
Gouley's  sounds,  592 
Gowers,  tuberculous  paraplegia,  638 
Grafts,  nerve,  659 

omental,  331,  358 
tendon,  1076 
Wolf's,  683 
Grafting  skin,  683 
Grant's  operation,  107 
Grattan's  osteoclast,  845 
Graves'  disease,  216 
Gray,  George,  appendicectomy,  376 
gastrectomy,  323 
infectious  hand,  1017 
prostatectomy,  585 
Green,  thoracic  surgery,  253 
Gregoire,  nephrectomy,  539 
Griffith,  J.  D.,  Dupuytren's  contracture 
II 17 


INDEX. 


II31 


Gritti's  amputation,  1059 
Griinbaum,  motor  centers,  18 
Grunert,  dislocation  clavicle,  961 
Grtinwald  pharyngotomy,  197 
Guerin  congenital  dislocation  hip,  890 
Guibe,  portal  anastomosis,  424 
Gum,  chewing,  hemostasis,  7 
Gurlt,  intracapsular  fracture,  791 

Habitual  dislocation,  patella,  933 

shoulder,  979 
Hacker,  v.,  gastro-enterostomy,  307 

tendon  transplantation,  1098 
Hadra,  adrenalectomy,  445 
Haeberlin,  skin  grafting,  686 
Haecker,  oesophagotomy,  192 
Haemorrhoids,  416 

Haffter,  osteoplastic  amputation,   1057 
Hagedom,  hare-lip,  122 
Hagen,  cyst  pancreas,  431 
Hahn  cannula,  208 
Hahn,  club-foot,  11 08 

pylorodiosis,  315 
Hallowell,  artery  suture,  692 
Hallux  valgus,  947 
Halstead,  aneurysm,  707 
Halsted,  excision  breast,  238 

hernia,  498 

hypoparathyroidism,  217 

intestinal  suture,  285,  286 

oesophageal  diverticulum,  194 

parathyroids,  216 

strumectomy,  226 

transplant,  parathyroid,  232 
Halstead,  A.  E.,  hypophysectomy,  51 
Hammestahr,  gastro-enterostomy,  314 
Hancock,  duodeno-choledochotomy ,  473 
Hand,  amputation,  1036 

infections  of,  10 12 
Handley,  ascites,  425 

excision  rectum,  404 

lymphangioplasty,  245,  750 
Hannequin,  osteotomy  hip,  872 
Hardie,  palmar  contracture,  11 16 
Hare-lip,  117 
Harrington  clamp,  307 

cystectomy,  572 

ring,  342 
Harris,  M.  L.,  dislocation  hip,  880 
Harris,  Wilfred,  brachial  palsy,  669 
Harris,  nephropexy,  521 
Harrison,  Damar  suture     vena      cava, 

541,  738 
Harrison,  R.,  drainage  bladder,  583 

vasectomy,  580,  619 
Harte,  injury  spinal  cord,  642 

spinal  tumors,  63  8 
Hartley,  Krause,  operation,  12,  67 
Hartmann,  cysticotomy,  467 

gastrostomy,  292 

intestinal  clamp,  285,  307 

ligation  vena  cava,  541 
Harvie,  gastrectomy,  300 
Hasslauer,  mastoiditis,  37 
Hauseman,  Trendelenberg's  operation, 
06^ 


Head  of  femur,  tract,  789 
operations  on,  i 

radius,  tract,  809 
Hearn,  excision  upper  jaw,  54 

ligature  external  carotid,  724 
Heart,  operation  on,  273 
Heidenhain,  pneumectomy,  272 
Heineke,  excision  rectum,  396 

pyloroplastly,  316 
Helferich,  ankylosis  patella,  927 

adrenalectomy,  445 

ankylosis  jaw,  94 

curvi-cuneiform  osteotomy,  925 
Hellin,  double  empyema,  259 
Hemmeter,  exploration  stomach,     290 
Hemorrhagic  pachymeningitis,  47 
Hemorrhage    after    intestinal     suture, 
286 

chest-wounds,  248 

gastric  ulcer,  290 

intestinal  urethrotomy,  591 

middle  meningeal  vessels,  13 

meningeal,  Gushing,  25 

neck  operations,  178 

pancreas,  432 

venous,  737 
Hemostasis,  amputation  hip,  1060 

disarticulation  shoulder,  1040 

liver,  449 

scalp,  6 

shoulder,  1040 

skull,  7 

temporary,  artery  stiture,  692 

veins,  737 
Hemp,  suture,  285 
Hepatectomy,  448 
Hepatic  abscess,  451 

cirrhosis  splenectomy  442 

tumors,  448 
Hepaticus  drainage,  467,  472 
Hepato-cholangio-enterostomy,  47,^ 
Hepatoptosis,  446 
Hepatotomy,  451 
Hepburn,  transfusion,  742 
Hernia  diaphragmatic,  510 

duodenojejunal,  507 

femoral,  487 

foramen  Winslow,  507 

inguinal,  491 

operation  for,  482 

large  and  irreducible,  510 

retroperitoneal,  507 

Treitz's,  507 

sliding,  487 

strangulated,  482 

umbilical,  502 

ventral,  505 
Hernial  sac,  implantation  in  dura,  46 
Herniotomy,  482 
Herten,  sarcoma  bones,  828 
Herrick's  clamp,  693 
Heusner,  prostatotomy,  589 
Hey's  amputation,  1052 

displaced  semilunar  cartilage,  908 
Hibbs,  congenital  dislocation  hip,  892 
Highmore  antrum,  80 


113- 


INDEX. 


Hildebrand,  excision  aneurysm,  708 

Freund's  operation,  265 

habitual  dislocation,  patella,   933 

muscle  transplantation,  674 

tumors  bone,  828 
Hill,  hydrocephalus,  38 
Hilton's  method,  651 
Hip,  congenital  dislocation,  883 

arthritis  deformans,  864 

joint,  853 

old  dislocation,  879 

osteotomy,  865 

sarcoma,  1066 
Hippel,  peristalsis     after    laparotomy, 

282 
Hirsch,  amputation,  1030 
Hirschsprung's  disease,  349 
Hochenegg,  hypophysectoray,  50 
Hoffa,  branchial  palsy,  676 

congenital  dislocation     hip,      890, 
892,  897 

excision  hip,  863 

tendon  transplantation,  1086 
Hofman's  laminectomy,  646 

exposure  base  skull,  89 
Hollow  foot,  1 1 13 
Hood,      Wharton,      function      patella, 

923 
Hook,  McBurney's,  972 
Hopkins,  Johns,  hernia,  497 
Horse-hair,  687 

-shoe  kidney,  544 
Horsley,    suture     recurrent     laryngeal 
nerve,  662 

decompressive  operations,  24 

hyperpyrexia  cerebral,  23 

hypophysectomy,  48 

meningocele,  37 

spina  bifida,  648 

sinus  thrombosis,  33 
Horsley's  wax,  7 
Horwitz,  epididymectomy,  621 

Bottini  operation,  581 
Hotchkiss'  operation,  100 
Hour  glass  stomach,  315 
Hubbard,  J.  C,  arteriovenous  anasto- 
mosis, 701 
Hubscher,  dislocation  knee,  920 
Hueter,  bunion,  947 

rhinoplasty,  161 
Huguier,  anchylosis  wrist,  1006 

arthroplasty  hip,  865 

fracture  astragulus,  944 
Humbert,  congenital    dislocation    hip, 

889 
Humerus,  fracture  dislocation,  977 

fracture,  763,  801 

sarcoma,  1045 
Hunner  suture,  338 
Hunkin,  tendon  suture,  1075 
Hunter's  operation,  706 
Huntington,  excision  hip,  860 

implantation  bone,  777 
Hutchinson,  J.  Jr.,  amputation  shoul- 
der, 1043 

Gasserian  ganglion,  70 


Hydatid  cyst  lung,  268 
Hydatids,  spleen,  442 
Hydrocele,  625 

neck,  183 
Hydrocephalus,  38 

callosal  puncture,  27 

ligature  common  carotid,  722 
Hydro-nephrosis,  546 
Hydrops,  articuli,  1023 

hip,  863 
Hyperemia,  infections  hand,  10 15 

mastoiditis,  37 
Hyperpituitarism,  47 
Hyperpyrexia,  cerebral,  23 
Hypertrophy  prostate,  580 

pylorus,  315 
Hypernephroma,  539,  542 
Hyperthyroidism,  215 
Hypoglosso-facial  anastomosis,     666, 

667 
Hypodermoclysis,  738 
Hypophysectomy,  47 
Hypo-pituitarism,  47 
Hypothyroidism,  215 
Hypoparathyroidism,  215 
Hypodermoclysis,  282,  290 
Hypospadias,  601 

Ideal  cholecystotomy,  456 

Idiocy,  38 

Idiopathic  epilepsy,  43 

Iliac  artery,  internal  ligation,  406 

arteries,  ligation,  730 

external  ligation,  1060 

vein,  phlebitis  ligation,  745 
Ileum,  tuberculosis,  384 
Ilium,  exposure  of,  847 
Imperforate  anus,  386 
Implantation  bone.  Oilier,  776 
bone,  764 

Huntington,  777 

in  dural  defects,  46 

membranes  in  knee,  930 

nerves,  659 

plates  and  wire  hernia,  505 

ureter  in  intestine,  555 

venous,  699 
Incision,  angular  goitre,  228 

cominon  duct,  467 

cystic  duct,  466 

exposing  bile  duct,  455 
hip,  954 
kidney,  513 

for  hernia,  482 

goitre,  231 

hydrocele,  625 

Jackson's,  245 

Larghi's,  879 

McArthur,  McBumey,  371 

arthrotomy  knee,  901 

perineal  prostatectomy,  584 

strumectomy,  222 

tuberculous  glands  neck,  179 

Warren's,  245 

abdominal,  277 

excision  upper  jaw,  83 


INDEX. 


^^33 


Incision,  pseudarthrosis,  767 
Indian  method,  rhinoplasty,  16  r 
Indication,   Hgation   superior  thyroid, 

726 
Indications,  arthrotoniy  knee,  905 

callosal  puncture,  28 

colostomy,  359 

enterectomy,  345 

excision  rectum,  391,  405 

exophthalmic  goiter,  220 

exploration,  stomach,  290 

for  operation,  fractures  skull,  17 

fractured  patella,  799 

for  amputation,  1026 

Freund's  operation,  264 

Gasserian  ganglion,  72 

gastro-enterostomy,  300 

interscapulothoracic     amputation, 

1045 
joints,  1023 
laryngotomy,  199 
ligation,  common  carotid,  721 

external  carotid,  724 

internal  carotid,  724 

lingual  artery,  725 

subclavian,  728 
lymphangioplasty,  752 
mastoid  operations,  28 
nephropexy,  522 
nephrostomy,  534 
operations,  appendicitis,  382 

facial  palsy,  668 

gall-stones,  477 

hip,  863 

knock-knee,  842 

meningocele,  37 

on  testes,  620 

pericardium,  273 

spinal  meningitis,  631 

tumors,  bone,  828 
partial  nephrectomy,  538 
pneumolysis,  260 
prostatic  hypertrophy,  580 
pulmonary  decortication,  257 
renal  operations,  541 
spinal  injuries,  639 
splenectomy,  441 
strumectomy,  218 
transfusioii,  742 
tuberculosis  knee,  919 
wry  neck,  177 
Infantile  palsy,  nerve  anastomoses,  676 
Infection,  cranial  contents,  28 
costal  cartilage,  267 
'  '  pericardium,  274 
Infections,  bone,  810 
ear,  28 

frontal  sinus,  53 
hand,  1012 
joint-,  1023 
Infective  phlebitis,  744 
Inferior  dental  nerve,  65 

maxillary     nerve,     injection,     58 

neurectomy,  65 

operation,  90 
mesenteric  artery,  407 


Inferior  thyroid  artery  ligation,  726 
Inflammations,  bone,  810 

hand,  1012 

mediastinum,  276 
Infra-orbital  nerve,  neurectomy,  64 
Infrapubic,  prostatotomy,  589 
Inguinal  colostomy,  360 

glands,  amputation  penis,  609 

hernia,  491 
Injections,  abscess,  652 

ankle,  936 

carbolic  in  ureter,  539 

elbow,  986 

for  neuralgia,  56 

hydrocele,  625 
neck,  183 

intravenous,  738 

iodoform,  hip,  853 

joints,  Murphy,  923 

knee,  900 

spina  bifida,    649 

vaseline,  hip,  853 
Injury  nerves  neck,  179 

musculo-spiral  nerve,  680 

spleen,  441 

thoracic  duct,  179 

to  nerves,  nephrotomy,  514 

to  pancreas  in  pylorectomy,  325 

vena  cava,  541 
Injuries,  amputation  for,  1027 

brachial  plexus,  669 

pancreas,  438 

to  spine,  639 
Intercricothyrotomy,  197 
Interilio-abdomen,   amputation,   1067 
Intermaxillary  bone,  hare-lip,  123,  131 
Intestinal  clamp,  283 

exclusion,  349,  369,  385 

obstruction,  351 

perforations,  331 

suture,  285 
Intestines,  operations  on,  331 
Internal  carotid,  ligation,  724 

derangement,  knee,  908 

hernia,  507 

iliac  artery,  ligation,  732 

jugular,  ligation,  ^^,  722 

piles,  416 

popliteal  nerve,  stretching,  679 

splinting,  bones,  772 

splints,   761 

urethrotomy,  590 
Interscapulo-thoracic  amputation,  1045 
Intertrochanteric,  osteotomy,  870 
Intoxication,  duodenal,  313 
Intra-meduUary  bone-pegs,  771 
Intravenous  injections,  738 
Intracranial    complications,  otorrhoea, 

Intraglandular  enucleation,  goitre,  230 
Intracapsular  fracture,  femur,  789 
Intratracheal  insufflation,  247 
Intubation,  excision  of  tongue,  145 
Intussusception,  353 
Invagination,  arterial  anastomosis,  696 
Iodine  in  goitre,  218 


1 134 


INDEX. 


Iodine,  injection,  hydrocele,  625 

spina  bifida,  649 
Iodized  catgut,  68g 
Iodoform  bone  plug,  815 

emulsion,  psoas  abscess,  653 

glycerine,  859,  900 

injection,  hip,  853 

starch,  818 

styptic  varnish,  141 
Irreducible  dislocation,  shoulder,  970 

hernia,  482,  510 
Irrigation,  meninges,  633 
Israel,  hydronephrosis,  548 

intussusception,  355 

nephrectomy,  539,  540 

nephropexy,  517 

rhinoplasty,  172 
Italian  method,  rhinoplasty,  163 
Ito  ascites,  426 

Jaboulay's  incision,  278,  373 

amputation,  1067 

gastrostomy,  292 

hydrocele,  629 
Jackson,  J.  N.,  excision  breast,  245 

Chevalier,  excision  thymus,  233 
Jacksonian  epilepsy,  45 
Jacobson,  amputation  foot,  105 1 

disarticulation,  shoulder,  1040 

excision  elbow,  988 
parotid,  153 
tongue,  145 

ligation  femoral  artery,  736 
superior  pole  thyroid,  726 

sacro-iliac  disease,  850 

spinal  injuries,  641 
Jacoel's  staples,  761 
Jaesche,  lower  lip,  114 
Jamison,  caecectomy,  346 
Jaundice,  calcium  chloride,  454 
Jaw,  cancer  of,  100 

excision,  preliminary     laryngot- 
omy,  197 

lower,  operation,  90 

temporary  resection,  190 

upper,  operation  on,  83 
Jaw  and  chin,  excision,  113 
Jeannel,  colopexy,  389 

varicose  veins,  749 
Jejunum,  position  of  origin,  305 
Jejunostomy,  359 
Jianu  facial  palsy,  669 
Johnston,  G.  Ben.,  necrotomy,  824 
Joint,    anchylosis    temporo-maxillary, 

94 
ankle,  936 
elbow,  986 
hip,  853 

congenital  dislocation,  883 
knee,  operations  on,  900 
sacro-iliac,  excision,  850 
shoulder,  operations  on,  962 
transplantation,  930 

elbow,  999 
wrist,  1002 
Joints,  fracture  involving,  765 


Joints,  indications,  1023 

transplantation,  781 

wounds  of,  1022 
Jonas,  adrenalectomy,  445 

dislocation,  shoulder,  975 

operation,  club-foot,  1107 
Jones',  Robert,  saw,  835 

semilunar  cartilage,  909 

tenotome,  11 00 

arthrodesis,  elbow,  992 

calcaneo-cavus,  11 13 

club  foot,  mo 

congenital  club  foot,    11 03,     11 04, 
1105 

creaking  knee,  920 

dislocation,  shoulder,  979 

osteotomy,  hip,  873 

tendon    transplantation,    1082, 
1084,  1085,  1087,  1090 
Jones,  W.  D.,  cholecystostomy,  461 
Jordan,  F.,  amputation  shoulder,  1043 

ligation,  common  carotid,  721 
Jonnesco,  closure  abdomen,  280 

epilepsy,  45 

facial  palsy,  669 

nephropoxy,  518 

peritoneal  fossae,  507 

splenectomy,  442 

sympathectomy,  185 
Jugular,  internal  ligation,  722 

vein,  ligation,  ^;} 

Kader,  gastrostomy,  294 
Kammerer's  incision,  278,  373 
Kanavel,  hypophysectomy,  50 

infections,  hand,  1012  et  seq. 
Karewski,  empyema,  255 
Karewsky,  pancreatic  fistulae,  434 
Katzenstein,  serratus  paralysis,  953 
Kaufmann,  salivary  fistulae,  155 
Kausch,  transplantation  bone,  782 
Keen,  epilepsy,  44 

excision  upper  jaw,  84 

forceps,  9 

Gasserian  ganglion,  67,  70 

laryngectomy,  202 

ventricular  drainage,  43 

wry  neck,  175 
Keetley,  bone  clamps,  772 
Kehr,  hepato-enterostomy,  473 

hepaticus  drainage,  467,  472 

cholecystectomy,  462 

incision,  455 

hepatopexy,  446 
Kelly,  umbilical  hernia,  504 

ureter,  550 

uretero-cystostomy,  555 
Kelsey,  excision  rectum,  405 
Kennedy,  R.,  brachial  palsy,  670 

wry  neck,  175 

facial  palsy,  664 
Kidney,  absence  of,  516 

anatomy,  524 

decortication,  534,  543 

exploration  of,  526 

excision,  538 


INDEX. 


II35 


Kidney,  horse-shoe,  544 

indications  for  operation,  541 

nephropexy,  516 

operations  on,  513 

remarks  on  operation,  541 

rupture,  541 

stone  in,  535 

tuberculosis,  542 
Killian's  operation,  54 

tracheoscopy,  210 
Kirmisson,  congenital  dislocation  liip, 

890 
Kirschner,  closure  dural  defects,  47 

hernia,  501,  505 
Klapp,  abscess,  652 

infectious  hand,  10 15 
Knee,  anchylosis,  924 

arthrotomy,  901 

arthritis  deformans,  919 

congenital  dislocation,  920 

creaking,  920 

disarticulation,  1059 

joint,  operations  on,  900 

injections,  900 

transplantation  of,  930 

tuberculosis,  919 
Knock-knee,  839 
Knott,  Van  B.,  amputation  gangrene, 

1027 
Knott,  hepatectomy,  451 
Kocher,  abdominal  incisions,  279 

angular  incision  goitre,  228 

amputation  hand,  1038 

arthrotomy  hip,  856 

cardiolysis,  275 

cholangiostomy,  473 

duodeno-choledochotomy,  472 

elbow  disarticulation,  1039 

empyema,  258 

epilepsy,  44 

excision  breast,  242 
elbow,  989 
hip,  860 
rectum,  396 
tongue,  142,  144 

exophthalmic  goitre,  218 

exposure  pelvic  bones,  847 

gastro-enterostomy,  305 

hepatectomy,  451 

hypophysectomy,  50 

incision  bile  duct,  456 

ligation  common  carotid,  718 
external  carotid,  724 
lingual  artery,  725 
superior  thyroid  artery,  725 

ligatures,  687 

orchidectomy,  621 

osteoplasty  upper  jaw,  89 

pericardium  273 

pylorectomy,  320 

resection    enucleation    goitre,    229 
shoulder,  964 

spinal  injuries,  640 

strumectomy,  222,  et  seq. 

tetany,  217 

wryneck,  174,  176 


Kolliker,  appendicectomy,  375 
Konig,  amputation,  foot,  1051 

cannula,  207 

excision,  ankle,  939 
hip,  857 
knee,  918 

exstrophy,  559 

hare-lip,  121 

incision,  nephrotomy,  515 

intracapsular  fracture,  789 

-Mialler  operation,  11 

rhinoplasty,  171 

tuberculosis  testes,  620 

urethral  fever,  592 

Fritz,  excision,  upper  jaw,  85 

exopexy,  thymus,  233 

fistulae,  neck,  184 

fracture,  humerus,  801 

fractures,  755 

rhinoplasty,  159 
Konitzer,  tumors,  bone,  829 
Korte,  cranial  defects,  1 1 

rupture,  kidney,  541 
Kramer,  sarcoma,  bones,  827 
Kraske,  excision,  rectum,  394,  395 
Krause,  angioma,  2 

Gasserian  ganglion,  67 

-Hartley  operation,  67 

injections,  ankle,  936 

injection,  hip,  853 

motor  centers,  18 

subdural  fluid  cord,  638 
Krogius's  excision,  angioma,  2 
Kronlein's  operation,  orbit,  81 
Kronlein,  meningeal  hemorrhage,  14 
Kulenkamff ,  excision,  pelvic,  bones,  848 
Kiimmel,  excision,  rectum,  397 

exophthalmic  goitre,  218 

spinal  meningitis,  631 

suture  femoral  artery,  700 

thoracoplasty,  257 
Kuster,  nephrotomy,  515 

hydronephrosis,  547 
Kiittner  transplantation,  bone,  782 

tumors,  bone,  829 

Labey,  tendon  transplantation,   1095 
Laceration,  kidney,  541 
Lacher,  diaphragm,  hernia,  511 
Lachrymal  nerve,  61 
Lambert,  arterial  suture,  692 
Lambotte,  drainage,  ascites,  425 

fractures,  805 
Laminectomy,  633 
Lane,  cleft  palate,  127 

hare-lip,  123 

intestinal  exclusion,  340 

microcephalus,  38 

operation  for  fractures,  755,  et  seq. 
Lange,  rectorrhaphy,  388 

suture  tendon  to  periosteum,  1078 

tendon  transplantation,  1085 
Langenbeck,  excision,  ankle,  937 

hip.  857 
tongue,   144 
Intracapsular  fracture,  789 


II36 


INDEX. 


Langenbeck,  lower  lip,  115 

rhinoplasty,  159,  161 

salivary  fistula,  154 

ankylosis,  knee,  924 

arthrotomy,  hip,  855 

clamp,  417 

cholangiostomy,  473 

incision,  nephrotomy,  515 
Lannelonge,      sclerogenic      injections, 
knee,  901 

microcephalus,  38 
Lanphear,  hemostasis,  6 
Laparectomy,  447 
Laparotomy,  277 

in  excision,  rectum,  395 

tuberculous  peritonitis,  384 
Larghi,  excision,  hip,  861 

incision,  hip,  879 
Laryngeal  nerve,  recurrent  suture,  662 
Laryngectomy,  196 

complete,  200 

partial,  198 

with  oesophagectomy,  204 
Laryngotomy,  196-198 

Butlin's  operation,  197 

preliminary,  145 
Lateral  anastomosis,  333 
Lavage,  knee,  900 
Lecene,  cardiolysis,  275 

thoracic  duct,  179 
Le  Conte,  interscapulo-thoracic  ampu- 
tation, 1045 

peritonitis,  381 

wounds,  chest,  249 
LeFort,  ligation  common  carotid,  721, 
Le  Fort's  amputation,  1055 
Leg,  amputation,  1034,  1055 
Lejar,  rupture,  urethra,  596 

foreign  bodies,  bronchus,  210 
Lembert  suture,  285 
Lennander's  incision,  278,  373 
Lepto-meningitis,  632 
Leriche,  statistics,  gastrectomy,  329 
Leucocythemia,  splenectomy,  442 
Levy,  injections,  neuralgia,  56,  57 
Lewis,  Dean,  deltoid  paralysis,  955 

urethral  stone,  551 
Lexer,  arterio-venous  aneurysm,  715 

rhinoplasty,  161,  167 

transplantation,  bone,  781 
joints,  930 

venous  implantation,  699 
Lichtenstern,  renal  tuberculosis,  542 
Ligament,  crucial  rupture,  912 

patellae  transplantation,  1079 
Ligation,  arteries  in  continuity,  716 

axillary  artery,  729 

brachial  arterj^  730 

carotid,  718 

carotids,  hydrocephalus,  40 

external  carotid,  84,  85 
iliac  artery,  1060 

femoral  artery,  735 

for  varicose  veins,  745 

goitre,  218 

iliac  arteries,  730 


Ligation,  inferior  thyroid,  726 

internal  carotid,  724 
iliac  artery,  406 

vein,  745 
jugular,  S3 
infection,  744 
vein,  722 

lingual  artery,  724 

piles,  417 

subclavian  artery,  727 

superior  pole  of  thyroid,  726 
thyroid  artery,  725 

temporary,  carotid,  182,  183 

vena  cava,  541 

vessels,  706 
Ligatures,  687 

elastic,  312,  314,  337 
liver,  449 
Lilienthal,  arterial  suture,  692 

wounds,  pleura,  246 
Linear  osteotomy,  835 
Lingual,  artery  ligation,  724 

nerve,  65 
Lip,  hare,  117 

lower,  operations  on,  103 
Liquid  air,  angioma,  4 
Lisfranc's  ampiitation,  105 1 
Lister,  patellar  fracture,  798 
Lithiasis,  biliary,  460 

pancreatic,  438 

ureter,  549 
Lithotomy,  common  duct,  467 

cystic  duct,  466 

suprapubic,  567 

perineal,  583 

ureteral,  551 
Liver,  abscess,  451 

operations  on,  446 
Llobet,  diaphragm,  hernia,  511 
Lloyd,  Jordan,  amputation,  1063 

tourniquet,  1061,  1062 
Lobule,  ear,  restoration,  73 
Location,  Rolandic  fissure,  18 
Longitudinal  sinus,  suture,  16 
Loose  bodies  in  knee,  907 
Lorenz,  club  foot,  1108 

congenital    dislocation,    hip,    890 
891 

strangulated  hernia,  486 

tendon  transplantation,  1083 

wry  neck,  174 
Loreta,  pyloric  stenosis,  316 
Lessen,  neurectomy,  64 
Lotheisen,  cholecystenterostomy,  466 

Dupuytrien's  contracture,  1117 

nerve  suture,  661 
Lothrop,  CoUes's  fracture,  787 
Low,  V.  W.,  brachial  palsy,  669 
Lower  jaw,  operations,  90 

lip,  operations  on,  103 
Lucke,  neurectomy,  64 
Lumbar  colostomy,  359 

nephrectomy,  538 

puncture,  629 

route,  nephrotomy,  513 
Lumbar  ureterostomy,  534 


INDEX. 


II37 


Lucke,  neurectomy,  64 
Lund,  club  foot,  1108 

sarcoma,  brachial  plexus,  1045 
Lung,  abscess,  gangrene,  268 

decortication,  257 

phthisis,  operation,  259 

tumor  of,  268 
Lungs,  wounds  of,  246 
Ltixation,  congenital  knee,  920 

hip,  congenital,  883 
Lymphatics,  caecum,  347 

cancer  tongue,  142,  143,  144,  146, 
148 
Lymphatic  glands,  neck,  178 

laryngectomy,  201 

larynx,  199 

lip,  103 

obstruction  of,  cancer  breast,  245 
Lymphatics,  penis,  609 

scalp,  4 

stomach,  320,  326 

testes,  616 
Lymphangioplasty,  245,  750 

Mc  Arthur,  gangrene,  lung,  268,  269 
hypophysectomy,  48 
prostatectomy,  571 

McBurney,  appendicectomy,  376 
compression,  iliac  artery,  1060 
duodeno-cholectochotomy,  472 
fracture-dislocation    of     shoulder, 

977 
McBumey's  hook,  972 
incision,  283,  371 
McCormac,     dislocation,     ulnar    nerve 

677 
McCosh,  spinal  injuries,  640 

vental  hernia,  505 
McGraw,    elastic    ligature,    312,    314, 

337 
McWilliams,  cholecystectomy,  478 
Maas,  hare-lip,  122 
Mabit,  echinococcic  cysts,  479 
Macdonald,  catgut,  689 
Macewen,  bow-leg,  843 

compression,  aorta,  1061,  1062 

cranial  defects,  1 1 

decompressive  operations,   24 

excision,  lower  jaw,  93 

infections,  brain,  etc.,  28 

implantation,  bone,  764 

inguinal  hernia,  491 

patellar  tract,  795 

transplantation,  bone,  782 

treatment,  hernial  sac,  488 

use  of  chisel,  833 

wounds,  pleura,  246 
Macewen's  drainage  tubes,  656 

operation,  aneurysm,  713 

osteotomy,  835 

triangle,  29 
Machine,  Bartlett,  892 
Mackinnon,  A.  I.,  dislocation,  shoulder, 

979 
Mackenzie,  K.,  sciatic  nerve,  662 
Mackenzie,  abdominal  pain,  351 

72 


Mackenzie's  law,  291 

Macleod,  imperforate  anus,  387 

Macnamara,  hip  disease,  860 

Macrotia,  72 

Madelung,  colostomy,  360 

Madelung,  large  herniae,  510 

Magnesium,  prosthesis,  artery,  695 

Maitland,    excision    lymphatics,    neck, 

148 
Mainzer,  tendon  transplantation,  1085 
Maiochi,  omentopexy,  428 
Maisonneuve,  urethrotome,  590 
Makin's  hirschsprung  disease,  349 

sacro-iliac  disease,  850 
Makkas',  exstrophy,  561 
Malcolm,  cyst,  pancreas,  430 
Maldeveloped  lower  jaw,  94 
Malgaigne's  operation,  hare-lip,   117 
Malignant  disease,  breast,  236 
intestine,  345 
intranasal,  157 
kidney,  538 
larynx,  199  ^/  seq. 
neck,  182 
parotid,  152 
rectum,  391,  et.  seq. 
stomach,  320 
testes,  615 
tongue,  see  Tongue, 
prostate,  587 
tumors,  bladder,  569 
bone,  827,  829 
pelvic  bones,  846 
scalp,  4 
thorax,  267 
Mallets,  833 
Malpositions,  hip,  865 
Malum  coxa  senilis,  876 
Malunion  fracture,  783 
Mamma,  operation  on,  235 
Mamourian,  varicose  veins,  746 
Mangold,  v.,  rhinoplasty,  172 
Manual  osteoclasis,  841 
Marchant,  rectopexy,  389 
Margary,    congenital   dislocation,    hip, 

890 
Marion,  laminectomy,  636 
Markoe,  brachial  palsy,  669 
Marsupialization  echinococcic  cyst,  480 
goitre,  231 
hydrocele,  neck,  183 
Martel,  portal  anastomosis,  424 
Martin,  prosthesis,  93 
pseudarthrosis,  766 
suture,  brachial  artery,  700 
Martini,  renal  decortication,  543 
Martinow,  horse-shoe  kidney,  544 
Marwedel,  nephrotomy,  533 
Matas'  constriction    common    carotid, 
721 
excision  upper  jaw,  84 
forced  respiration,  247 
ligation  of  external  carotid,  724 
operation,  109 
thoracic  surgery,  253 
Mastoid,  infection  of,  28 


1 138 


INDEX. 


Mastopexy,  235 
Mastoptosis,  235 
Maunsell,  excision,  rectum,  411 
Maunsell's  operation,  340 
Maury's  experiments,  312 

gastro-enterostomy,  310 

ligature,  310 

thoracic  surgery,  253 
Maxilla,  inferior,  operations,  90 

temporary  resection,  190 

superior,  operations  on,  83 
Maxillary  nerve,  inferior  injection,  58 
neurectomy,  65 
superior  injection,  59 

neurectomy,  61 
Maxwell,  intracapsular  fracture,  790 
Maydl  v.,  implantation  ureters,  555 

jejunostomy,  359 
Maydl's  operation,  560 
Maylard,  gastrostomy,  293 

intestinal  clamp,  284 
Mayo     Brothers,     aneurysmorrhaphy, 
711 

bunion,  949 

cholecystostomy,  461,  465,  469 

cleft  palate,  138 

cystectomy,  572 

diverticulitis,  349 

epilepsy,  44 

excision  rectum,  398 
ulcer  stomach,  299 

exophthalmic  goitre,  2  i  g 

fractures,  764 

gastro-enterostomy,  308 

hare-lip,  117 
.  hypospadias,  603,  606 

ligation     superior     pole     thyroid, 
726 

omentopexy,  423 

pancreatitis,  438 

plastic  surgery,  682 

pylorectomy,  322 

splenic  anaemia,  444 

statistics,  gastrectomy,  329 

strumectomy,  225 

suture,  pelvis  kidney,  536 

tuberculosis,  ureter,  539 

tuberculous  peritonitis,  384 

umbilical  hernia,  502 

varicose  veins,  745,  746 
Mears,    dislocation,  shoulder,  971 

vasectomy,  580 
Meatotomy,  590 
Median  cervical  fistulae,  184 
Mediastinum,  posterior,  275 
Mediastinitis,  276 
Medical  treatment,  goitre,  218 
Meltzer,      intratracheal,      insufflation, 

247 
Membranes,  animal,  implantation,  930 
Membrane  Cargile's,  47,  358 

Hand's,  47 

preventing  adhesions,  brain,   11 
Meninges,  cancer  of,  5 

prevention,  adhesions,  11 

spinal,  tumor,  639 


Meningeal  hemorrhage,  Gushing,  2  5 

vessels,  hemorrhage,  13 
Meningocele,  operative  treatment,  37 

spine,  647 
Meningitis,  hydrocephalus,  39 

serosa  spinalis,  639 

spinal,  63  I 
Mesenteric  suture,  338 
Mesentery,   echinococcus  cysts,  479 
Mesosigmoiditis,  357 
Meshwork,  wire,  in  hernia,  505 
Metacarpo-phalangeal     dislocations, 

1008 
Methods  of  closing  abdomen,  280 

of  opening  abdomen,  277 
skull,  6 

proctoclysis,  382 

respiration,  chest  operations,2  47 
Meyer,  anuria,  543 

cabinet,  247 

excision,  breast,  242 

prostatotomy,  581 

wire  mesh,  hernia,  505 
Microcephalus,  38 
Middle  meningeal  hemorrhage,  13 
Mikulicz,  cardiospasm,  290 

congenital  dislocation,  hip,  889 

exstrophy,  560 

gastric  ulcer,  291 

gastroenterostoiny,  313 

hydrocephalus,  38 

jejunostomy,  359 

pancreas,  432 

peptic  ulcer,  314 

prolapsus,  recti,  389 

pyloroplasty,  316 

repair  of  bladder,  576 

resection  goitre,  228 

wry  neck,  174 
Milroy's  disease,  753 
Mirault,  hare-lip,  118 
Misplaced  testicle,  621 
Mitchell,  lymphangioplasty,  753 

suture,  338 
Mixter,  canunla,  739 

colostomy,  362,  364 

hypophysectomy,  52 

needle,  280 

oesophageal  diverticula,  193 

spinal  injuries,  640 

tube,  364 
Mobile  spleen,  441 
Mocquot,  pyelotomy,  537 

renal  pelvis,  525 
Mohr-Freund's  operation,  265 
'MoUiere,  dislocation,  shoulder,  970 
Momburg,    compression,    aorta,    1061, 
1063 

dislocation,  ulnar  nerve,  677 
Monari,  ureteral  anastomosis,   553 
Monod  and  Van  verts',  wry  neck,i77 
Monod,  anchylosis,  jaw,  95 

results    arterio-venous    anastomo- 
sis, 703 
Moore,  J.  E.,  excision,  hip,  859 

intracapsular  fracture,  790 


INDEX. 


II39 


Moorhof,  colostomy,  361 
Morgagni  foramen  hernia,  5  1 1 
Morison,  cardiolysis,  275 

cholecystotomy,  459 

empyema,  252 

excision,  hip,  863 
knee,  918,  919,  920 

incision,  456 

nephrotomy,  516 

intestinal  exclusion,  350 

omentopexy,  422 

ureterotomy,  549 

ventral  hernia,  506 
Morris,  anatomy,  ureter,  545 

anuria,  543 

sarcoma,  bone,  828 

ureterotomy,  549 
Mortality,  gangrene,  lung,  268 
Mortou's  fluid,  spina  bifida,  649 
Morphine  after  laparotomy,  282 
Mosetig's  bone  plug,  815,  638,  859 
Mosny,  pleurisy,  251 
Motor  centres,  18 
Mouth  gags,  127,  136 
Mouth,  floor  of,  cancer,  14S 
Moynihan,  gastric  ulcer,  290,  291 

gastroenterostomy,  307 

intestinal  clainp,  285,  307 

prostatectomy,  571 

pylorectomy,  328 
Mozkowicz,   amputation  for  gangrene 

1026 
Mliller,   W.,   arthritis,  deformans,  knee, 
919 

congenital  dislocation,  hip,  904 

flat-foot,  107 1 

Konig  operation,  1 1 

pseudoarthrosis,  776 
Mummery,  excision,  rectum,  399 
Munro,  J.  C,  gastroenterostomy,  309 

pachymeningitis,  47 

subdural  fluid,  card,  638 
Murphy,  abscess,  652 

air  embolism,  178 

anchylosis,  elbow,  996 
jaw,  94 

anterior  poliomyelitis,  676 

arterial  anastomosis,  696 

arterial-venous  anastomosis, 7 02 

arthroplasty,  hip,  865 
knee,  928 

button,  314,  336,  341 

fracture,  olecranon,  806 

gelatine  plug,  921 

injections,  knee,  900 
neuralgia,  56,  58,  60 

intestinal  clamp,  284 
suture,  331 

nerve  suture,  660 

orchidectomy,  621 

tuberculous  patella,  921 

peritonitis,  381 

pneumothorax,  260,  268 

proctoclysis,  382 

spinal  injuries,  639 
meningitis,  63  t 


Murphy,  syringomyelia,  642 
Muscle,  division  wry  neck,  174 

relative  strength,  1091 

transplantation,  facial  palsy,     669 
brachial  palsy,  673 
Muscle  transplantation  serratus  paral- 
ysis, 953 
Musculo-spiral  nerve,  680 
Myelo-cystocele,  spine,  647 
Myelocele,  spine,  648 
Myers,  Halstead,  absence  tibia,  780 
Mynter,  hydronephrosis,  547 

resection,  wrist,  1004 
Myotomy  dislocation,  shoulder,  970 

wryneck,  174,  176 
Myomectomy,  wry  neck,  174 
Myx oedema,  216 

Nailing  bones,  770 
Narath,  laryngectomy,  204 

omentopexy,  423 

Treitz  hernia,  507 
Nasal  nerve,  61 

Nash,  pancreatic  glycosuria,  433 
Nasopharyngeal  tumors,  89,  157 
Nassilov,  posterior  mediastinum,  275 
Nearthrosis,  shoulder,  982 
Neck,  humerus,  fractures,  801 

hydrocele,  183 

operations,  178 

wry,  1 74 
Necrosis,  clavicle,  959 
Needle  for  artery  suture,  692 

Brophy's,  125 

Deschamp's,  138 

intestinal,  285 

holder,  Lane's,  127 

Reverdin's,  280 
Nelaton,  anchylosis  wrist,  1006 

arthroplasty  elbow,  996 
hip,  865 

coloboma,  ear,  74 

excision,  lower  lip,  107 

operation,  hare-lip,  117 

rhinoplasty,  159,  164 
Neoplasms,  bladder,  568 

bone,  827 

brain,  18 

breast,  235 

cerebral,  decompression,  24 

cervical,  178 

chest  wall,  267 

hypophysis,  47 

liver,  448 

lower  jaw,  96 

pelvic  bones,  846 

rectum,  391,  et  seq. 
Neoplasms,  scalp,  i 

spinal  cord,  638 

stomach,  320 

tongue,  140 
Nephrectomy,  538 

examination  opposite  kidney,   516 

partial,  537 
Nephritis,  decortication.  534.  545 
Nephrolithotomy,  535 


1 140 


INDEX. 


Nephrolithiasis,  double,  537 
Nephrotomy,  531 

anuria,  543 
Nephrorrhaphy,  516 
Nephropexy,  516 
Nephrostomy,  534 
Nerves,  alterative,  operations,  678 

anastomosis,  664 

anterior  poliomyelitis,  676 

blocking,  1044,  1147 

brachial  plexus,  injuries,  669 

cervical  sympathetic,  185 

disassociation  fibres,  678 

division,  wry  neck,  175 

exterior  popliteal  stretching,  679 

facial,  mastoid  operation,  30 
operation  on  parotid,  152 
stretching,  680 
suture,  658 

frontal,  61 

hypoglossal,  666 

implantation,  659 

in  amputation,  1031 

infraorbital  neurectomy,  64 

inferior  dental,  65 

inferior  maxillary,  injection,  58 
neurectomy,  65 

injury  in  fracture,  783 

injury  to,  nephrotomy,  514 

interior  popliteal,   stretching,   679 

lachrymal,  61 

lingual,  65 

musculo-spiral,  680 

nasal,  61 

operation  in  trifacial,  56 

operation  on,  657 

ophthalmic  injection,  60 

peroneal,  stretching,  679 

plastic  operations,  659 

radial  suture,  662 

recurrent  laryngeal  suture,  662 

roots,  posterior  division,  643 

sciatic  resection,  662 
stretching,  679 

spinal  accessory,  666 

stretching,  678 

supraorbital,  61 

supratrochlear,  61 

superior  maxillary,  injection,  59 
neurectomy,  61 

suture,  657 

ulnar  dislocation,  677 

vagus,  injury,  179,  183 
Nevus,  scalp,  i 
Neuber,  drainage  tubes,  656 

iodoform  starch,  818 

osteoplasty,  821 
Neugebauer,  diaphragm,  hernia,  511 
Neuralgia,  sympathectomy,  188 
Neuralgia,  trifacial,  56 
Neurasthenia,  gastric,  291 

nephropexy,  522 
Neurectomy,  56 

sciatic,  662 

wry  neck,  175 
Neuritis,  678 


Neuromata,  amputation,  103 1 
Neurorrhaphy,  657 
Necrotomy,  816 
Nicoladoni,  flat-foot,  1070 
NicoU,  amputation,  penis,  608 

cerebrospinal  drainage,  41 

pyloroplasty,  317 
Nimier,  prosthesis,  93 
Nitrogen-pneumothorax,  260 
Nitze,  vesical  neoplasms,  569 
Niuni,  exposure  pericardium,  273 
Nodes,  lymph,  lip,  103 
No-loop  gastroenterostomy,  308 
Non-union  fracture,  766 
Nose,  operation  on,  157 
Nove-Josserand,  hypospadias,  604 

Obliteration,  bone  cavities,  815 
Obliterative    endoaneurysmorrhapy, 

709 
Obstruction,  intestinal,  351 

permanent,  common-duct,  473 

pylorus,  315  et.  seq. 

ureter,  546 
Obturator  dislocation,  hip,  881 
Occipital  nerve,  division  of,  176 
Ochsner,  excision,  ankle,  940 

appendicitis,  382 

empyema,  252 

oesophageal  stricture,  195 

pseudarthrosis,   766 
O' Conor,  echinococcic  cysts,  481 

rheumatic  arthritis,  1025 
Odontomata,  96 
CEdema,  lymphangioplasty,  750 
(Esophagus,  operations  on,  192 
CEsophageal  stenosis,  292 
CEsophagectomy,  204 
Qisophagotomy,  192 

in  posterior  mediastinum,  276 
CEstreich,  adrenalectomy,  445 
Ogston,  club-foot,  11 09 

excision,  lip,  105 

fiat-foot,  1069 

osteotomy,  839 
Olecranon,  fracture,  806 
Olivier,  excision,  thymus,  233 
Oilier,  autoplasty,  bone,  775 

chondrectomy,  831 

excision,  ankle,  938 

excision,  elbow,  989 

excision,  hip,  862 

excision,  scapula,  959 

excision,  shoulder,  962 

excision,  wrist,  1002 

nearthrosis,  shoulder,  982 

osteotomy,  tibia,  844 
Ombredanne,  arthroplasty,  elbow,  998 

lower  lip,  107 

undescended  testes,  623 
Omental  graft,  331 

grafts,  358 
Omentopexy,  422 
Omentum,  echinococcic  cysts,  479 

herniotomy,  483 
Operation,  abdominal,  283 


INDEX. 


II4I 


Operation,  alterative,  nerves,  678 
anchylosis,  jaw,  94 

knee,  924 

wrist,  1006 
antrum,  Highmore,  80 
antrus,  706 

appendicitis,  indications,  382 
Bassini's  hernia,  487,  493 
Bevan's,  622 
bone  tumors,  827 
Bottini's,  579 
brachial  palsy,  669 
Brasdor's,  706 
bunion,  947 
cancer,  penis,  608 
cardiospasm,  290 
cleft  palate,  125 
Codman's  bursitis,  985 
congenital  dislocation,  hip,  889 

knee,  920 
decompressive,  24 
diaphragm,  510 
direct  transfusion,  739 
dislocation,  elbow,  993 

fingers,  1008 

hip,  879 

shoulder,  970 
Dix's,  707 
Dollinger's,  181 

Dupuytren's  contracture,  11 16 
echinococcic  cysts,  479 
elbow  anchylosis,  996 
emphysema  and  phthisis,  264 
Estlander's,  256 
exstrophy,  557 
facial  palsy,  664 
Ferguson's  hernia,  495 
flat-foot,  1069 
Foerster's,  643 
for  aneurysm,  704 
for  club-foot,  1 102 
for  deformity,  hip,  865 
for  epilepsy,  43 
for  epispadias      and    hypospadias, 

598,  601 
for  fistula  in  ano,  420 
for  hernia,  482 
for  hydrocephalus,  38 
for  meningocele,  37 
for  encephalocele,  3  7 
for  obstruction,  bowels,  351 
for  phthisis,  259 
for  sacro-iliac,  dislocation,  850 
for  special  fracture,  789 
for  tic  douloureux,  56 
for  ununited  fracture,  766 
fracture,  humerus,  801 

olecranon,  806 

OS  calcis,  801 

tubercle  tibia,  800 
genito-urinary,  513 
habitual  dislocation,  shoulder,  979 
hare-lip,  117 
horse-shoe  kidney,  544 
Hunter's,  706 
hydrocele,  625 


Operation,  infections,  hand,  1012 
infective  phlebitis,  744 
Kraske's,  394 
lymphangioplasty,  750 
Macewen's  aneurysm,  713 

hernia,  491 
malunion,  fracture,  783 
Matas',  709 
Mayo's  hernia,  502 
Morison's  hernia,  506 
on  ankle,  936 
on  appendix,  371 
on  arteries,  692 
on  biliary  passages,  454 
on  breast,  235 
on  cheek,  97 
on  chest,  246 
on  clavicle,  952 
on  elbow,  986 
on  frontal  sinus,  53 
on  gall-bladder,  456 
on  heart,  273 
on  hip-joint,  853 
on  kidney,  513 
on  knee,  900 
on  intestines,  331 
on  liver,  446 
on  lower  jaw,  90 
on  lower  lip,  103 
on  mastoid,  28 
on  neck,  178 
on  nerves,  657 
on  nose,  157 
on  oesophagus,  192 
osteomyelitis-necrosis,  etc.,  810 
osteotomy,  832 
on  pancreas,  428 
on  parotid,  152 
on  pericardium,  272 
on  pituitary  body,  47 
on  pylorus,  315 
on  rectum,  386 
on  scapula,  952 
on  shoulder-joint,  960 
on  spine,  629 
on  spleen,  440 
on  stomach,  289 
on  suprarenal  bodies,  445 
on  tendon  and  sheaths,  1072 
on  testicles,  615 
on  thymus,  233 
on  tongue,  140 
on  urethra,  590 
on  urinary  bladder,  557 
on  veins,  737 
on  wrist,  1002 
patellar  fracture,  793 
Payr's  ventricular  drain,  40 
pelvic  bones,  S46 
pelvis,  kidney,  536 
Phelps',  club-foot,  1105 
plastic,  bone,  775 
post  mediastinum,  275 
plastic,  external  ear,  72 
pleural  cavity,  250 
pruritus  ani,  419 


II42 


INDEX. 


(Operation,  psoas  abscess,  652 

reduction     dislocation,     patella, 

933 

renal  calculus,  535 

rupture,  bladder,  563 

separation,  femoral  epiphysis,  792 

serratus  paralysis,  952 

simple  fracture,  754 

for  spina  bifida,  646 

spinal  meningitis,  631 

syndactylism,  1009 

Syme's,  aneurysm,  707 

thrombosis  and  embolism,  700 

trifacial  neuralgia,  56 

trigger  finger,  loio 

tuberculous  paraplegia,  638 
peritonitis,  384 

undescended  testes,  621 

upper  jaw,  83 

urethral  rupture,  595 

Vautrin's,  467 

varicocele,  627 

varicose  veins,  745 

Wardrop's,  706 

Woods',  ectopia  vesicas,  557 

WuUstein's,  hernia,  506 
Ophthalmic  division,  V  nerve,  61 

nerve,  injection,  60 
Opiate  after  laparotomy,  252 
Orbit,  exposure  of,  81 
Os  calcis,  945 

fracture,  801 
Osteitis  rib,  tubercular,  266 
Osteoclasis,  844 

knock-knee,  841 
Osteoclasts,  845 
Osteoma,  pelvis,  846 
Osteomata,  827 
Osteoplasty,  775 

skull,  9-1 1 -1 2 
Osteoplastic  amputation,   1056 

exposure,  orbit,  81 

laminectomy,  635 

resection,  upper  jaw,  89 
Osteoplasty,  819 
Osteo-sarcoma,  827 
Osteotomes,  832 
Osteotomy,  832 

club-foot,  1 108 

dislocation,  shoulder,  1)71 

flat-foot,  1069 

hip,  865 

knee,  924 

lower  jaw,  94,  95 

malunion,  fracture,  783 

Pott's  fracture,  788 

supraarticular,  931 
Osteomyelitis,  810 

hip,  863 

pelvis,  846 

scapula,  957 
Ostwalt,  injections,  neuralgia,  56 
Otis,  urethrotomy,  590 
Otitis  media,  28 
Otorrhcea,  operations  for,  29 
Overcorrection,  club-foot,  1104 


Pachnio,  colopexy,  389 
Pachymeningitis,  hemorrhagic,  47 
Paci,  congenital  dislocation,  hip,  890 
Parker,   Rushton,  osteotomy,  hip,  874 
Pads,  abdominal,  289 
Pagenstecher's  suture,  687 
Palate,  temporary  resection,  89 
Palate,  cleft,  125 
Palm,  infections  of,  1012 
Palmar  fascia  contracture,   11 16 

pouches,  1012 
Pancreas,  428 

excision,  434 

tumors,  434 

in  pylorectomy,  325 

in  ulcer,  stomach,  299 
Pancreatic  calculi,  438 

fistulae,  434 

traumata,  438 
Pancreatitis,  433 

acute,  437 

chronic,  438 

subacute,  438 
Pancreatectomy,  435 
Papilomata,  bladder,  568 
Paracentesis  abdominalis,  424 

hydrocephalus,  38 

pericard,  272 
Paralysis,  brachial,  669 

deltoid,  674,  955 

Duchenne  Erb,  669 

extensors,  toes,  1086 

facial,  664 

infantile,  nerve  anastomosis,  676 

musculo-spiral,  680 

serratus,  952 

shoulder,  978 

trapezius,  952 
Paralytic  eversion,  leg,  1099 

fiat-foot,  107 1 
Paraphimosis,  614 
Paraplegia,  spastic,  643 

tuberculous,  638 
Parathyroid  glands,  215 

transplantation,  231 
Parham,  sarcoma,  chest,  267 
Park,  R.,  cholecystectomy,  478 
Park,  meningeal  hemorrhage,  14 
Parkes'  incision,  nephrotomy,  515 

intestinal  operations,  335,  339 
Parkhill,  bone  clamps,  772 
Parotid  gland,  operation  on,  152 
Partsch,  excision  lower  jaw,  92 
Passler  Freund's  operation,  265 
Paste,  Beck's,  819 
Patella,  fracture,  793 

anchylosis,  927 

dislocation  of,  933 

tuberculosis,  921 
Patrick,  injections,  neuralgia,  56,  60 
Paul,  colectomy,  348 

tube,  364 
Pawlik,  cystectomy,  577 
Payr,  arterial  suture,  695 

arthroplasty,  knee,  928,  930 

plastic  operation,  ear,  75,  78 


INDEX. 


"43 


Payr,  transplantation,  thyroid,  231 

tabes,  nerve  suture,  60 

ventricular  drainage,  40 
Pean,  intestinal  clamp,  284 

nephropexy,  517 

rectotomy,  390 
Pearse,  hyperpyrexia,  cerebral,  23 
Pearson,  catgut,  689 
Peck,  arthrotomy,  knee,  904 

cleft  palate,  139 
Peckham,  dislocation,  shoulder,  977 
Pectoralis  major,  transplantation,  674 
Pegs,  bone,  770 
Pelvic  bones,  846 

colon,  blood  supply,  407,  412 
Pelvis,  kidney,  536 

anatomy,  524 
Penis,  amputation,  608 
Peptic  ulcer,  314 
Perforating  gastric  ulcer,  291 

ulcer,  foot,  678 
Perforation,  duodenum,  331 
Perforator,  Doyen's,  10 
Pericaecal  fossae,  508 
Pericardiocentesis,  272 
Pericardium,  operations  on,  272 
Pericardiotomy,  273 
Perier,  laryngectomy,  201 
Perineal  cystotomy,  582 

lithotomy,  583 

prostatectomy,  584 

section,  582 
Periosteal  autoplasty,  780 
Periosteum,  in  amputation,  1030 
Periosteotome,  Brophy's,  137 
Periostitis,  810 

pelvis,  846 
Peritoneal  fossae,  507 
Peritoneum,  afifections  of,  371 

perforating  ulcer  stomach,  297 
Peritonitis  from  pancreatic  juice,  433 

general,  380 

tuberculous,  384 
Perkins,  J.  W.,  exstrophy,  559 

osteotomy,  93 1 
Perles',  empyema,  255 
Peroneal  nerve,  stretching,  679 
Peroneus  tendon,  dislocation,  1080 
Perthes,  habitual  dislocation  shoulder, 

980 
Petersen,  cardiolysis,  275 

gastro-enterostomy,  313 
Phalangeal  dislocation,  1008 

diverticula,  193 
Phalanges,  disarticulation,  1035 
Pharyngotomy,  196 

transhyoid,  150 
Phelp's  club-foot,  1105 

dislocation,  shoulder,  976 

umbilical  hernia,  505 

varicose  veins,  746 
Phimosis,  613 
Phlebitis,  infective,  744 
Phlegmon,  mediastinum,  276 
Phthisis,  operations  for,  259 
Physostigmin  after  laparotomy,  282 


Picot,  gangrene  lung,  269 
Picque,  sacro-iliac  dislocation,  850 
PiersoU,  parathyroids,  216 
Piles,  operation  on,  416 
Pilcher,  knock-knee,  840 
Pinna,  ear,  operation  on,  72 
Pins,  Trendelenburg's,  1060;  106 1 

Varick's,  1060,  1061 

Wyeth's,  1060,  1061 
Pirogoff's  amputation,  1054 
Pituitary  body,  47 
Plantar  fasciotomy,  iioi 
Plastic  excision  upper  jaw,  84 

operation  anus,  388 
bone,  775,  820 
cheek,  97 
external  ear,  72 
gall  passages,  474 
nerv^es,  659 
nose,  158 

repair  oesophagus,  204 

surgery,  principles,  681 
Plates,  implantation  hernia,  505 

Lane's,  772 
Pleura,  operation,  250 

wounds  of,  246 
Pleurisy,  Blocquee's,  251 
Plication  stomach,  296 
Plugs,  bone,  815 

Murphy's  gelatine,  921 
Pneumatic  cabinets,  247 
Pneumococcal  arthritis,  1025 
Pneumectomy,  268,  271 
Pneumolysis,  260 
Pneumopexy,  268 
Pneumothorax,  artificial,  260,  268 

treatment  of,  249 
Pneumotomy,  268 
Podrez,  exposure  pericardium,  273 
Poggi  congenital  dislocation  hip,  890, 

897 
Poirier,  Gasserian  ganglion,  71 
Polaillon,  dislocation  shoulder,  970 
Poliomyelitis    anterior,    nerve   anasto 

mosis,  676 
Poncet,  transplantation,  insertion  ten- 
don, 1079 
Ponfick,  hepatectomy,  448 
Popliteal,    external    nerve,    stretching, 
679 

internal  nerve,  stretching,  679 
Portal  vein,  anastomosis,  424 
Porter,  C.  B.,  pancreatitis,  438 
Position,  excision  tongue,  141,  143,145 

in  operation  empyema,  252 

kidney  operation,  513 

patient  laparotomy,  282 

Rose's,  117 

Trendelenburg's,  117 
Post,  mediastinum,  275 
Posterior  gastro-enterostomy,  307 
Posture  bihary  operations,  454 

in  excision  rectum,  395 

in  peritonitis,  381 
Potarco,  operation,  piles,  418 
Powers,  neurorrhaphy,  659 


II44 


INDEX. 


Pravaz,  congenital  dislocation  hip,  889 
Precaution  against  losing  laparotomy 

pads,  289 
Preliminary  colostomy,  404 
laryngotomy,  145,  197 
treatment,  arthrotomy,  900,  901 
cystotomy,  564 
excision  rectum,  391,  400,  411 
operations  on  knee,  923 
perineal  cystotomy,  582 
piles,  416 
urethrotomy,  590 
tracheotomy,  208 
Preparation    for    perineal    cystotomy, 
582 
for  urethrotomy,  590 
Senn's  bone  chips,  8i8 
sutures  and  ligatures,  687 
Preparatory  treatment,   gastric  opera- 
tion, 289 
Pressure  cerebral  decompression,  24 

differential,  cabinet,  247 
Prevention  adhesions  meninges,  11 
Principles  arterial  suture,  692 
cardiac  operations,  274 
intestinal  suture,  335 
nephropexy,  520 
operation  hare-lip,  117 
inguinal  hernia,  497 
plastic  surgery,  681 
tendon  transplantation,  1081 
treatment  rectal  prolapse,  387 
spinal  injuries,  639 
Pringle,  rupture    crucial    ligature,  912 
Probe,  Thrailkill's,  421 
Process,  coronoid,  fracture,  808 
Proctoclysis,  282,  738 

Murphy's  method,  382 
Prognosis    congenital    dislocation    hip, 
883 
excision  ankle,  942 
Prolapse  spleen,  441 
Prolapsus  recti,  387 
Prominent  ears,  74 
Prophylaxis,  epilepsy,  43 
Prostatic  cancer,  587 

hypertrophy,  580 
Prostatectomy,  570 

perineal,  584 
Prostatotomy,  578 

infrapubic,  589 
Prosthesis  after  excision  jaw,  91 
Proust,  excision  rectum,  400 
Pruritus  ani,  419 

Pseudo-arthrosis  hip,  Jones  R.,  876 
Pseudarthrosis,  766 
Psoas  abscess,  652 
Pterygo-maxillary  neurectomy,  64 

-palatine  fossa,  157 
Ptosis  colon,  nephropexy,  521 

liver,  446 
Pubis,  symphysis,  excision,  848 
Pulmonary  abscess  and  gangrene,  268 
decortication,  257 
phthisis  operation,  259 
Pump,  Bunsen's,  252 


Puncture,  ankle,  936 

callosal,  27 

knee,  900 

pericardium,  272 

pleura,  250 

spinal,  629 

ventricles,  43 

wounds  of  joints,  1022 
Purves,  facial  palsy,  664 
Pyarthros,  hip,  863 
Pyelotomy,  536 
Pyelo-lithotomy,  536 
Pylorectomy,  319 
Pyloroplasty,  316 
Pylorodiosis,  315 
Pylorus,  operations  on,  315 
Pyonephrosis,  542 

Quenu,  arthroplasty  elbow,  998 

excision  rectum,  406 
scapula,  959 

iliac  arteries,  730 

sarcoma  hip,  1066 
Quervain,  de,  goitre,  218 

Radial  nerve,  680 
suture,  662 
Radical  cure  femoral  hernia,  487 
hydrocele,  625 
inguinal  hernia,  491 
umbilical  hernia,  502 
Radiculitis,  operation  for,  643 
Radius,  fracture  head,  809 

malunion  fracture,  787 

sarcoma  of,  828 
Racemose  angioma  scalp,  2 
Ramsauer,  nerve  suture,  661 
Ramus,  jaw  resection,  90 
Ransohoff,  fracture  skull,  17 

indication  kidney  operation,  542 

ligation  common  cartoid,  722 

umbilical  hernia,  502 
Ranula,  184 

Rasumowsky,  anastomosis  vas,  617 
Recessus  duodenojejunalis,  hernia,  507 
Reconstructive  aneurysmorrhaphy ,  712 
Rectal-continuous  instillation  salt  solu- 
tion, 382 
Rectus,  incision,  279 
Rectopexy,  388 
Rectorrhaphy,  388 
Rectotomy  posterior,  390 
Rectum,  blood  supply,  407,  412 

operations  on,  386 

prolapse,  387 

stricture,  390 

tumors  of  391,  et  seq. 
Recurrence,  tumors  bone,  828 
Reccurrent  dislocation  patella,  933 

laryngeal  nerve  suture,  622  '^ 
Reduction  old  dislocation  hip,  879 

shoulder,  970 
Reeve's  knock-knee,  840 
Regnier's  flaps,  682 

operation,  104 
Regnoli- Billroth,  excision  tongue,  142 


INDEX. 


1 145 


Rehn,  callosal  puncture,  27 

excision  rectum,  395 

exopexy  thymus,  233 
Reinhardt,  resection  upper  jaw,  89 
Remarks,  amputation  penis,  609 

antrum  Highmore,  81 

appendicitis,  382 

arthrotomy  knee,  905 

ascites,  426 

castration,  620 

excision  ankle,  942 
knee,  918 
seminal  vesicles,  620 

exstrophy,  562 

gasserian  ganglion,  72 

intestinal  anastomosis,  344 

irreducible  hemise,  510 

ligation  arteries,  716 
common  carotid,  721 
external  carotid,  724 

malunion  Colles's  fracture,  787 

mobile  kidney,  522 

neurectomy,  66 

prostatic  hypertrophy,  580 

operation  for  coxitis,  863 
gall  stones,  477 

renal  operations,  541 

retrophar.  abscess,  189 

tendon  transplantation,  1083 

thyrotomy,  199 
tumors,  bone,  827 

vasectomy,  620 

wry  neck,  177 

wounds  diaphragm,  511 
Removal,  loose  bodies,  knee,  907 
Renal  anatomy,  524 

calculus,  535 

decortication,  534,  543 

tuberculosis,  542 
Renton,  femoral  hernia,  489 
Roosevelt's  clamps,  307 
Repair  crucial  ligaments,  912 

defects  cheek,  98 

of  nerves,  657 
Respiration  during  thoracic  operation, 

247 
Resection  ankle,  937 

aorta,  700 

brachial  artery,  700 

elbow,  986 

enucleation  goitre,  229 

femoral  artery,  700 

goitre,  228 

hip,  856 

intestine,  345 

knee,  916 

liver,  449 

lower  jaw,  90 

nerves  neuralgia,  56,  61 

rib,  252 

sciatic  nerve,  662 

shoulder,  962 

temporary,  lower  jaw,  190 

temporary,  palate,  89 

tumors  bone,  827 

upper  jaw,  89  « 


Resection  wrist,  1002 

Results,  arterial  venous    anastomosis, 

703 
Bottini's  operation,  581 
cardiolysis,  275 
colopexy,  389 

complete  excision  thyroid,  216 
congenital  dislocation  hip,  896 
diaphragmatic  hernia,  511 
excision  rectum,  397 
fiat-foot,  1069 
hypophysectomy,  50,  52 
injury  thoracic  duct,  179 
interscapular     thoracic     amputa- 
tion, 1045 
intussusception,  357 
late  fracture  skull,  1 5 
ligation  common  carotid,  721 
nerve  suture,  662 
omentopexy,  422 
operation  epilepsy,  44 
renal  tuberculosis,  542 
spinal  cord  and  tumors,  638 
tumors,  bone,  828 
varicose  veins,  749 
pancreatitis,  438 
resection  stomach,  329 

upper  jaw,  89 
sacro-iliac  dislocation,  852 
suture  heart,  274 
tuberculous  peritonitis,  384 
Retrograde  catheterization,  594 

•strangulation  hernia,  486 
Retro-maxillary  fossa,  157 
Retroperitoneal  hernia,  507 
Retro-pharyngeal  abscess  and  tumor, 
189 
tumors,  89 
Revenstorf,   suture  longitudinal  sinus, 

16 
Reverdin  A.,  needle,  280 
Rheumatic  arthritis,  1025 
Rhinophyma,  157 
Rhinoplasty,  158 
Rib,  fracture  pneumothorax,  249 
resection,  253 
tuberculosis,  266 
Richardson,    M.    H.,     oesophagotomy, 

i93>  195 

tuberculous  peritonitis,  385 
Richter,  artificial  respiration,  247 
Ricketts,  plastic  operation  ear,  78 
Ridlou,  club-foot,  11 04 
Riedl,  bunion,  947 

cholecystectomy,  462 

flat-foot,  1069 

ligature  subclavian,  728 
Rixford,  cancer  chest,  267 

closure  thoracic  defects,  268 

neurorhaphy,  658 
Robinson,    Samuel,    thoracic    surgery, 

253 
Robson,  Mayo,  calcium  chloride,  454 
crucial  ligaments,  912 
duodeno-choledochotomy,  472 
gastrolysis,  292 


II46 


INDEX. 


Robson,     indications,     operation     gall 

stones,  477 

incision,  455 

jaundice,  432 

pancreatitis,  433,  439 

peptic  ulcer,  3 14 

position,  454 

pylorectomy,  320 
Rochet,  anchylosis  lower  jaw,  95 

arthroplasty  hip,  866 
Rodent  ulcer  excision,  87, 
Rodman,  ulcer  stomach,  292 
Rolando,  fissure  location,  18 

osteomyelitis,  812 
Rolfe,  castration,  616 
RoUeston,  ascites,  422 
Rongeur,  for  mastoid  operation,  35 
Roots,  posterior  nerve  division,  643 
Ropke,  laminectomy,  636 
Rose,  congenital  dislocation  hip,  890 

Gasserian  ganglion,  67 

position,  117 
Rosenberger,  hypospadias,  604 
Rotschild,  trapezius  paralysis,  955 
Rotter,  excision  rectum,  397,  414 

fracture  patella,  799 
Roux,  after-treatment  gastro-  enteros- 
tomy, 290 

amputation,  1054 

femoral  hernia,  489 

gastroenterostomy,  313 

pleural  induration,  258 

typhoid,  costal  cartilage,  257 
Rovsing  cystectomy,  577 

dry  arthritis,  1025 

gastropexy,  297 

pyelolithotomy,  537 

transplantation    bone    and    joint, 
781 

ureterostomy,  534 

vaseline  injections,  900 
hip,  853 
Rubber  tissue,  in  trephining,  11 
Rubritius,  osteomyelitis,  812 
Ruggi,  tumor  pancreas,  434 
Rules  against  losing  laparotomy  pads, 
289 

finding  site  obstruction,  351 
Rupture,  bladder,  563 

crucial  ligaments,  912 

kidney,  541 

urethra,  595 
Ruth,  intracapsular  fracture,  790 

pancreatic  calculi,  438 
Rutkowski,  exstrophy,  560 

gastroenterostomy,  314 

repair  defects  bladder,  575 
Ruotte,  ascites,  426 
Rydygier,  splenopexy,  440 

excision  rectum,  392 


Sabanjeff's  amputation,  1059 
Sac,  hernial,  483 

dural  defects,  46 
hernia  treatment,  488 


Sacculated  aneurysm,  705 
Sacral  route  excision  rectum,  394 
Sacro-iliac  disease,  850 
Saddle  nose,  171 
Saenger,  nerve  suture,  662 
Salivary  fistula,  154 

glands,  operation  on,  152 
Salkindsohn  catgut,  689 
Salt  solution,  intravenous  injection,  738 
Sand-bag,  836 

Saphenous  vein,  excision,  etc.  746 
Sarcoma,  bone,  827 

brachial  plexus,  1045 

chest,  267 

clavicle,  960 

hip,  1066 

humerus,  781 

neck,  182 

parotid,  153 

pelvic  bones,  847 

pelvis,  847 

shoulder,  1045 

spinal  cord,  638 
Sauerbruch  cabinet,  253 

differential  cabinet,  r47 
Saul,  catgut,  689 
Saws,  835 

electric,  10 

Gigli,  skull,  10 
Sayre,  osteotomy  hip,  870 
Scalp,  malignant  tumors,  4 

operations,  i 

lymphatics,  4 
Scapula  alata,  952 

excision,  956 

operations  on,  952 
Scars,  excision  in  epilepsy,  44 
Schafer,  artificial  respiration,  253 
Schede,  aseptic  blood  clot,  818 

congenital  dislocation  hip,  889 

suture  vena  cava,  737 

thoracoplasty,  257 

varicose  venis,  748 

wounds  of  veins,  737 
Schiassi,  omentopexy,  423 
Schimmelbusch,  rhinoplasty,  166 
Schlange,  excision  rectum,  396 

exstrophy,  559 

dislocation  elbow,  994 

fracture  neck,  humerus,  978 
dislocation  shoulder,  977 
Sclerogenic  injections,  knee,  901 
Schlosser,  injections  in  neuralgia,  56 
Schmidt,  excision  acetabulum,  848 

pancreatic  fistulas,  434 
Schmieden,  hypospadias,  604 
Scoop,  gall-stone,  460 
Schiiller,  nerve  suture,  660 
Schulze  Berge,  closure  dural  defects,  16 
Schulten,  necrotomy,  819 
Schwartz,  bronchotomy,  211 
Sciatica,  678 
Scudder,  intestinal  clamp,  285 

separation  femoral  epiphysis,  792 
Sebaceous  cysts,  i 
Section  abdominal,  277 


INDEX. 


II47 


Sedillot,  excision  tongtie,  142 

Segond  exstrophy,  560 

Segregation,  intestinal,  349,  369,  385 

Seidel,  Freund's  operation,  265 

Semilunar  cartilage  displaced,  908 

Seminal  vesicles,  61S 

Semon,  laryngectomy  partial,  199 

Senn,  orchidectomy,  621 

Senn's,  bone  chips,  818 

ferrules,  772 
Separation  epiphysis  humerus,  802 

femoral,  epiphysis,  787,  792 
Sequestrotomy,  816 
Serratus  paralysis,  952 
Serre,  lower  lip,  116 
Seton  in  salivary  fistula,  155 
Sencert,  ampulla  Vater,  473 
Shepherd,  enucleation  goitre,  231 
Sherman,    congenital    dislocation    hip, 

896 
Sherrington,  motor  centers,  18 

posterior  nerve  roots,  144 
Shock,  amputation  in,  1027 

cranial  operation,  23 
Shoe,  club-foot,  11 12 
Sheaths,  tendon  operation  on,  1072 
Shoulder  arthrodesis,  978 

arthroplasty,  980 

bursitis,  985 

disarticulation,  1040 

dislocation,  969,  979 

fractures,  801 

joint,  operations  on,  962 

sarcoma,  1045 
Sick,  nerve  suture,  662 
Siegrist,  ligation  common  carotid,  721 
Sigmoid,  blood  supply,  407,  412 

sinus  operation,  32 

volvulus,  357 
Sigmoidectomy,  348 
Sigmoidostomy,  360 
Sigmoidopexy,  389 
Silk  ligatures,  687 

sutures,  intestinal,  285 
Silkworm  gut,  687 
Simon,  cardiolysis,  275 

dislocation  shoulder,  970 
Simon's  incision,  nephrotomy,  513 
Simple  fracture  operation,  754 
Sinus  cavernous  wound,  70 

frontal,  53 

longitudinal  suture,  16 

sigmoid  operation,  32 
Site  of  amputation,  1028 
Skin-grafting,  683 
Skull,  base,  exposure  of,  89 

cancer  scalp,  5 

decompression,  24 

exposure  of,  6 

fractures,  15 

fracture  base  operation,  25 

methods  of  opening,  6 
Sliding  hemiae,  487 
Small  intestine  excision,  345 
Smith,  2rtery  suture,  694 

clamp,  417 


Smith,  hepatotomy,  452 

Greig,  obstruction,  352 

splenectomy,  441 
Snapping  finger,  loio 
Sokoloff,  rectal  stricture,  391 
Solly,  club-foot,  1 108 
Solution   for  injections,  neuralgia,   56, 

57 

Murphy's,  652,  900 

salt  intravenous,  738 
Souchon,  dislocation  shoulder,  975 
Sonnenburg,  exstrophy,  560 

rectal  stricture,  391 

repair  cheek,  99 

vesical  tumors,  569 
Soyesima,  ascites,  426 
Spasm  pylorus,  315 
Spasmodic  torticallis,  175 
Spasticity,  operation  for,  643 
Special  fractures,  789 
Spleen,  echinococcic  cysts,  479 

operations  on,  440 

transplantation  thyroid  into,   231 
Splenic  ansemia,  444 
Splenectomy,  441 
Splenopexy,  440 

Spence,  amputation  shoulder,  1042 
Spencer,  dislocation  hip,  880 
Sphincter,  ani,  plastic  operation,  388 
Spiller,  decompressive  operation,  25 

facial  palsy,  668,  669 

Foerster's  operation,  643 

Gasserian  ganglion,  67 
Spina  bifida,  646 
Spinal  accessory,  nerve  division,  175 

anaesthesia,  63 1 

meningitis,  631 
Spine,  injuries  to,  639 

operations  on,  629 
Spino-facial  anastomosis,  667 
Splinting,  bones,  internal,  772 
Splints,  club-foot,  1105 
Sponge  count,  289 
Sprengel,  exposure  pelvic  bones,  846 
Spring  finger,  loio 
Spur  on  OS  calcis,  945 
Stabb,  cardiolysis,  275 
Stamm,  ligation  superior  pole  thyroid, 

726 
Stamm-Kader,  gastrostomy,  294 
Strangulated  hernia,  482, 

retograde,  486 
Staple  bone,  761 
Starch,  iodoform,  818 
Statistics,  arterio-venous  anastomosis, 

703 
Bottini  operation,  581 
cardiolysis,  275 

congenital  dislocation  hip,  896 
diaphragmatic  hernia,  511 
excision  rectum,  397 
exophthalmic  goitre,  218 
flat-foot,  1069 
fracture  skull,  15,  17 
gangrene  lung,  268 
heart  suture,  274 


1 148 


INDEX. 


Statistics,  interscapulo-thoracic  ampu- 
tation 1045 

intussusception,  357 

ligation  common  carotid,  721 

nerve  suture,  662 

omentopexy,  422 

operations,  tumors,  bone,  828 

pacreatitis,  438 

renal  tuberctilosis,  542 

resection  stomach,  329 

Sacro-iliac  disease,  852 

sympathectomy,  188 

tetany,  217 

tuberculous,  peritonitis,  384 

tumors  spinal  cord,  638 

operations,  varicose  veins,  749 

Whitehead's  operation,  142 
Stenger,  mastoiditis,  37 
Steno's  duct,  fistula,  154 
Stenosis  pylorus,  315,  et  seq 

trachea,  203,  214 
Sterilization  catgut,  688 

ligatures  and  sutures,  687 
Steiner,  middle  meningeal  artery,  14 
Steinmann,  direct  extension  bone,  785 
Stein  thai  pylorectomy,  326 
Stern,  pleurisy,  251 

Sterno-mastoid,  division,  wry  neck,  174 
Stettiner,  hypospadias,  604 
Stewart, artery  anastomosis,  700 

facial  palsy,  666 

injury  spinal  cord,  642 

operation,  iii 
Stich,  arterio-venous  aneurysm,  715 
Stieda,  cranial  defects,  1 1 
Stimson  dislocation  phalanges,  1008 

patellar  fracture,  795 
Stomach  cancer,  320 

hour-glass,  315 

operations  on,  289 

results  resection,  329 

ulcer,  290 
Stromeyer,  imperforate  anus,  387 
Stone,  common  duct,  467 

gall,  460 

in  bladder,  567 

in  cystic  duct,  466 

in  ureter,  549 

kidney,  535 

pancreatic,  438 
Stone,  J.  S.,  implantation  bone,  778 
Stoyanov,  posterior  mediastinum,  275 
Stratton  aneurysm,  707 
Stricture  oesophagus,  193,  195 

rectum,  390 

ureter,  546 

urethra,  590 

urethral,  excision,  594 
Struma,  215 

Strumectomy,  after  treatment,  221 
Struthers,  tracheotomy,  207 
Stubenrauch's  operations,  474 
Studsgaat,  resection  wrist,  1004 
Stump,  amputation,  1028,  1029 

in  appendicectomy,  375 
Styptic  varnish,  141 


vSubacromial  bursitis,  985 
Subastragaloid  dislocation,  944 
Subclavian  artery  ligation,  727 
Subcutaneous  division  sterno-mastoid, 

174 

operation  tuberculous  glands,  •181 
Submental  phlegmon,  184 
Suboccipital  nerve,  division  of,  176 
Subperiosteal  abscess,  813 
Subphrenic  abscess,  453 
Sub-temporal  decompressive  operation, 

24 
Subtrochanteric  osteotomy,  870,  874 
Sudeck,  excision  rectum,  407 
Summers,  cholecystostomy,  460 

gangrene  intestine,  358,  484 
Superficial  femoral  artery  ligature,  735 
Superior  maxilla,  operations  on,  83 

maxillary  nerve,  injection,  59 
neurectomy,  61 

thyroid  artery  ligature,  725 
Suppuration  hip,  863 

frontal  sinus,  53 
Suppurative  disease  middle  ear,  28 
Supraarticular  osteotomy,  93 1 
Supracondyloid  osteotomy,  835 
Suprahyoid  pharyngotomy,  197 
Suprameatal  triangle,  29 
Supraorbital  nerve,  56,  61 
Suprapubic  cystotomy,  564 

lithotomy,  567 

prostatectomy,  570 
Suprarenal  bodies,  445 

in  nephrectomy,  539 
Supratrochanteric  osteotomy,  865 
Supratrochlear  nerve,  61 
Suter,  tendon  suture,  1073 
Sutherland,  hydrocephalus,  38 
Sutton,  intratracheal  insufflation,  247 

hydronephrosis,  546 

lower  lip,  107 

Stubinranch's  operation,  476 
Sutures,  687 

abdomen,  280 

bladder,  566 

circular,  trachea,  203 

Connell's  342 

cystic  duct,  466 

diaphragm,  511 

hare-lip,  120 

heart,  274 

intestinal  285,  332 
principles,  335 

longitudinal  sinus,  16 

nerves,  657 

of  arteries,  692 

of  kidney,  532 

of  veins,  737 

pelvis  kidney,  536 

radial  nerve,  662 

recurrent  laryngeal,  662 

stomach,  290 

tendons,  1072 

ureter,  552 

urethra,  594 

vena  cava,  541 


INDEX. 


1 149 


Suturing  bones,  770 
Sylvian  fissure,  18 
Syme's  amputation,  1053 

operation,  aneurysm,  707 

urethral  guide,  592 
Syms,  Parker,  prostatectomy,  585 

tractor,  584 
Sympathectomy,  45,  185 
Symphysis  pubis,  excision,  848 
Symptoms,  congenital  dislocation  hip, 

885. 
Synchondrosis,  sacroiliac  excision,  850 
Syndactylism,  loog 
Synechia  lobule  ear,  74 
Synovial  sheaths  hand,  1012 
Synovialis  hip  excision,  858 

in  amputation  shoulder,  1043 
Synovialectomy  knee,  914 
Syringomyelia,  642 

Tabes,  Foerster's  operation,  646 
Tags,  in  knee,  911 
Talipes  calcaneus,  11 12 

cavus,  1 1 13 

equino-varus,  1102 
Talma,  omentopexy,  422 
Tanton,  hypospadias,  604 
Tansini,  portal  anastomosis,  424 
Tarsectomy,  club-foot,  1107 
Tavernier,  ascites,  424 
Taylor,  brachial  palsy,  670 

Foerster's  operation,  645 

resection  wrist,  1004 
Teale's  gorget,  582 

Temporary  hemostasis  arterial  suture, 
692 

occlusion  common  carotid,  722 

resection  lower  jaw,  190 
Temporo-maxillary  anchylosis,  94 

-sphenoidal  abscess,  3 1 
Tendo  Achillis,  section  in  flat-foot,  1070 
tenotomy,  iioo 
transplantation  insertion,  1080 
Tendon  as  suture,  688 

grafts,  1076 

sheath's  hand,  1012 
operation  on,  1072 

shortening,  1080 

substitution,  1075 

suture  of,  1072 

to  periosteum,  1078 

transplantation,  1081,  et  seq. 
flat-foot,  107 1 
insertion,  1079 
Tenorrhaphy,  1072 
Tenotomy,  iioo 

dislocation  shoulder,  970 

wry  neck,  174 
Tenotomes,  iioo 
Tension,  relief  of,  hare-lip,  117,  119 

renal  decortication,  534,  543 
Terrier,  cysticotomy,  467 

gastrostomy,  292 

osteotomy,  hip,  872 
Terrilon,  orchidectomy,  621 
Testis,  undescended,  621 


Testicles,  operations  on,  615 
Tetany,  216 

transplantion  thyroid,  231 
Thane,  sylvian  fissure,  19 
Thermo-taxic  centers,  23 
Thiersch,  epispadias,  598 

neurectomy,  56,  61 

grafts,  683 
Thigh,  amputations  1060 
Thiosinimin,  195 
Thirst  after  laparotmy,  282 
Thomas'  forceps,  1060,  1061 

wrench,  11 04 
Thomas,    H.    .0,    simulated  paralysis, 
1081 

osteotomy  hip,  874,  876 
Thomas,  Lynn,  fracture  patella,  779 

operation  breast,  235, 
Thomas,  Thelwell,  operation  piles,  416 
Thomas,  Turner,  capsulorrhaphy,  979 
Thoracic  deformity  cause  of  phthisis, 
etc.,  264 

duct  injury,  179 
Thoracectomy,  256 
Thoracentesis  pleura,  250 
Thoracoplasty,  256 
Thoracotomy,  251 
Thorax,  closure  defects,  268 

operations  on,  246 

tumors  of,  267 
Thorburn,  spinal  injuries,  641 
Thornton, injury    vena  cava,  541 
Thrailkill,  excision  fistula,  421 
Thrombosis,  operative  treatment,  700 

sigmoid  sinus,  32 
Thyrotomy,  199 
Thumb,  infectious,  1020 
Thymus,  gland,  operations  on  233 
Thyroglossal  duct,  persistent,  184 
Thyroid  artery  inferior  ligament,   726 
superior  ligament,  725 

gland,  215 

ligation  superior  pole,  726 

transplantation,  231 
Tibia,  congenital  absence,  780 

fracture,  763 
tubercle,  800 

osteotomy,  840,  844 
Tibial  tuberosity  transplantation,  1079 
Tibialis  anticus  tenotomy,  iioi 

posticus  tenotomy,  11 01 
Tic  douloureux,  56 
Tietze,  Foerster's  operation,  643 
Tillmans,  osteomyeUtis  pelvis,  846 
Tillaux,  orchidectomy,  621 
Time  to  operate,  appendicitis,  382 
Tongue,  oi>erations  on,  140 

preliminary  laryngotomy,  197 

thyroglossal  tumors,  184 

tumors  of  base,  197 
Topography,  brain,  18 
Torticollis,  174 
Tourneur's  point,  545 
Trachea,  foreign  bodies  in,  210 
Tracheal  stenosis,  203,  214 
Tracheoscopy,  210 


115© 


INDEX. 


Tracheotomy,  206 

excision  tongue,  145 

for  foregin  bodies,  210 

tubes,  207 
Tractors,  prostatic,  584 
Transfusion  blood,  739 

cannula,  742 

vein  to  vein,  743 
Transgastric  partial  gastrectomy,   298 
Transhyoid  pharyngotomy,  196 
Transmaxillary  neurectomy,  66 

operation,  157 
Transperitoneal  nephrotomy,  515 
Transplantation  tendon  flat-foot,  107 1 
Transplantation  bone,  780 
jaw,  93 

cartilage  to  elbow,  999 

fascia  hernia,  501,  505 

insertion  tendon,  1079 

muscle  facial  palsy,  669 
surratus  paralysis,  953 

nerves,  660 

of  joints,  930 

tendons,  1081,  et  se-. 
fiat-foot,  107 1 

Thyroid  and  parathyroid,  231 

with  arthroplasty,  781 
Trap  door,  skull,  10,  12 
Trapezius  paralysis,  952 
Trauma  pancreas,  438 
Traumata,  amputation  for,  1027 

brachial  plexus,  669 

spine,  639 
Traumatic  arthritis,  1023,  1025 
Treatment  abscess,  651 

after,  cleft  palate,  127,  139 
dislocation  elbow,  994 

hip,  881 
excision  hip,  857,  860 
jaw,  91 

lip,  115 

rectum,  398 

tongue,  141,  143,  145 
exterior  urethrotomy,  594 
fracture  olecranon,  806 

patella,  800 
gastrostomy,  296 
gastrostomy,  290,  296 
interior  urethrotomy,  592 
laparotomy,  282 
laryngectomy,  201,  203 
nerve  suture,  661 
oesophagotomy,  193 
operation  frontal  sinus,  54 

hernia,  497    a 

hypospadias,  606 

piles,  417 
pneumolysis,  264 
pylorectomy,  329 
resection  wrist,  1002 
skin-grafting,  686 
strumectomy,  221 
tendon  suture,  1078 

transplantation,  1087 
thoracoplasty,  259 
anchylosis  elbow,  9q6 


Treatment  anchylosis  knee,  924 

wrist,  1006 
aneurysm,  704 
appendicitis,  382 
arthritis  deformans  hip,  864 
arterio-venous  aneurysm,  714 
ascites,  421,  427 
before  cystotomy,  564 

gastric  operation,  289 

operation  for  haemorrhoids,  416 
on  tongue,  140 
perineal  cystotomy,  582 
urethrotomy,  590 
bow-leg,  843 
brachial  palsy,  669 
bunion,  947 
chest  wounds,  248 
club-foot,  1 102 
Codman's  bursitis,  985 
congenital  dislocation  hip,  889 

knee,  920 
deformities  hip,  865 
diseases  ankle,  936 

knee,  900 

hip,  853 
dislocation  fingers,  1008 

hip,  879 

shoulder,  970 
dry  arthritis,  853 
Dupuytren's  contracture,  11 16 
facial  palsy,  664 
flat-foot,  1069 

foreign  bodies  in  trachea,  210 
goitre,  218 
habitual  dislocation  patella,  933 

shoulder,  979 
hepatic  abscess,  451 
hydrocele,  625 
hydrocephalus,  38 
infectious  hand,  1012 
joints,  indications,  1023 
knock-knee,  839 
malunion  fracture,  783 
meningocele,  37 
encephalocele,  37 
obstruction,  351 
old  dislocation  elbow,  993 
open  fracture,  763 
operation  simple  fracture,  754 
osteomyelitis,  810 
patellar  fracture,  793 
prostatic  hypertrophy,  580 
pseudarthrosis,  766 
separation  femoral  epiphysis,   792 
rupture  crucial  ligament,  912 

urethra,  595 
serratus  paralysis,  952 
special  fractures,  789 
shock,  1028 
spina  bifida,  646 
spinal  injuries,  639 
syndactylism,  1009 
syrnigomyelia,  643 
thrombosis,  700 
trigger  finger,  10 10 
tumors,  bone,  827 


INDEX. 


II5I 


Treatment  ulcer  stomach  and    duode- 
num, 291 
urethral  fever,  592 
varicose  veins,  745 
wounds  diaphargm,  571 
joints,  1022 
Treitz,  hernia,  507 
Trelat,  lower  lip,  116 
Trendelenburg's  cannula,  207 
Trendelenburg,  excision  rectum,  411 
exstrophy,  558 
intracapsular  fracture,  789 
lower  lip,  114 
phlebitis  iliac,  745 
position,  282 
varicose  veins,  745 
Trephining,  6 

sacro-iliac  synchon,  850 
Treutlein,  excision  aneurysm,  708 

nerve  suture,  661 
Treves,  psoas  abscess,  652 
ligation  subclavian,  728 
pseud  arthrosis,  766 
Triangle,  suprameatal,  29 
Trifacial  neuralgia,  56 
Trigger  finger       10 10 
Trigeminal  neuralgia,  56 
Trochanteric  osteotomy,  869 
Trzebicky,  osteoplastic  amputation, 

1056 
Tubby,  brachial  palsy,  673 
Tubes,  drainage  in  pleura,  252 
Fauntleroy's  transfusion,  743 
Paul's  Mixter's,  364 
tracheotomy,  207 
Tubercle  tibia,  fracture,  800 
Tuberculosis  adrenals,  445 
ankle,  936 
bladder,  570 
intestine,  345 
kidney  and  ureter,  539 
knee,  900,  919,  et  seq. 
patella,  921 
pelvis,  846 

pulmonary,  operation,  259 
renal,  542 
ribs,  266 

vertebral,  638,  652 
wrist,  1004 
Tuberculous  arthritis,  1024 
coxitis,  863 
epididymis,  620 
glands,  neck,  178 
paraplegia,  638 
peritonitis,  384 
Tuberosity  os  calcis  fracture,  801 
Tuberosities  humerus  fracture,  802 
Tubular  suture  nerves,  660 
Tufiier,  complete  cystectomy,  576 

hypospadias,  604 
Tumors,  adrenals,  445 

base  tongue  and  epiglottis,  197 

brain.  18 

breast,  235 

bladder,  568,  583 

cerebral,  decompression,  24 


Tumors,  cervical,  178 

cheek,  97 

chest  wall,  267 

intestine,  345 

kidney,  538 

liver,  448 

lower  jaw,  96 

malignant  intranasal,  1 5  7 

oesophagus,  276 

of  bone,  827 

of  hypophysis,  47 

of  lip,  103 

orbit,  81 

pancreas,  434 

parotid,  152 

pelvic  bones,  846 

pylorus,  320 

rectum,  391  ^^  seq. 

retrophar,   189 

scalp,  I 

scapula,  956 

spinal  cord,  638 

spinal  meninges,  639 

stomach,  320 

tongue,  140 
Turner,  ascites,  422 
Tuttle  excision  rectum,  411 
Tympanic  attic,  disease  of,  3 1 
Typhoid,  costal  cartilage,  267 
Typhoidal  arthritis,  1025 
coxitis,  863 

Ulcer,  bladder,  570 

duodenal,  331 

of  stomach,  290 

peptic,  314 

perforating  foot,  678 

rodent,  excision,  87 

stomach,  excision,  298 
Ulcers,  varicose,  748 
Ulna,  fracture,  806 

sarcoma  of,  828 
Ulnar  nerve  dislocation,  677 
Umbilical  hernia,  502 
Undescended  testis,  621 
Undeveloped  lower  jaw,  94 
Union  of  bones,  methods,  770 
Ununited  fractures,  766 
Upper  jaw,  operations  on,  83 
Uranoplasty,  127 
Urban,  laminectomy,  635 
Uremia  after  nephrectomy,  516 
Ureter  in  nephrectomy,  539 
Ureteral  anastomosis,  553 
Urethral  fever,  592 

graft,  hypospadias,  604 
rupture,  595 
stricture,  590 
Uretero-cystostomy,  554 

-Uthotomy,  551 
Urethrectomy,  594 
Urethrotomy  external,  592 
Urethrotome,  590 
Ureterotomy,  534,  549.  55 » 

internal,  590 
Ureterectomy,  553 


II52 


INDEX. 


Urinary  bladder,  herniotomy,  483 
operations  on,  557 
extravasation,  595 
system,  513 

Vagus,  injury  to,  179 

section,  183 
Vallas,  excision  tongue,  150 

patellar  fracture,  795 

pharyngotomy,  196  • 

Van  Arsdale's  fluid,  398 
Van  Hook,  hypospadias,  606 

ureteral  anastomosis,  553 

ureterocystostomy,  555 
Vanghetti's  amputation,  1048 
Van  verts'  anchylosis  jaw,  95 

wry  neck,  177 
Vautrin  cholecystotomy,  459 

common  duct,  467 

intestinal  exclusion,  350 
Varnish,  iodoform  styptic,  141 
Varicose  aneurysm,  704 

veins,  745 
Varicocele,  627 

Vas,  deferens,  anastomosis,  617 
Vascular  supply  lower  bowel,  407,  412 

surgery,  692 
Vaseline  in  artery  suture,  692 

injections  hip,  853 
knee,  900 
Vasectomy,  580,  618 
Vater,  ampulla,  473 
Vaughan,  TuUy,  dislocation    shoulder, 
970 

wounds  heart,  274 
Veau,  excision  thymus,  233 
Vein,  femoral  injury  to,  736 

renal,  526 

internal  jugular  ligation,  722 

jugular  ligation,  33 

to  vein  transfusion,  743 
Veins,  drainage  into  in  ascites,  426 

operations  on,  737 

varicose,  745 
Veit,  peritonitis,  384 
Velpeau's  incision,  83 
Vena  cava  in  nephrectomy,  541 

suture  of,  737 
Venous  anastomosis  ascitis,  424 

implantation,  699 
Ventral  hernia,  505 
Ventricles  and  hyperpyrexia,  23 

callosal  puncture,  27 

drainage  of,  38,  39 
Vercesco's  operation  piles,  418 
Verga,  neurorrhaphy,  660 
Verhoogen,  cystectomy,  378 
Vermiform  appendix,  371 
Verneuil,  rectopexy,  388 
Vertebrae,  tuberculosis  of,  638,  652 
Vertebral  canal,  operation  on,  633 
Vesical  diverticulum,  568 

tumors,   568 
Vesicles,  seminal,  618 
Vicious  circle,  306,  312,  313 
Vidal,  portal  anastomosis,  424 


Villard,  ascites,  424 
Voelker,  renal  tuberculous,  542 
Vogel,  peristalsis  after  laparotomy,  282 
Vogt,  middle  meningeal  artery,  14 

Sylvian  fissure,  19 
Volkmann,  excision  knee,  916 

hydrocele,  625 
Volvulus,  357 
Vredene,  amputation,  1049 
Vulpius,  flat-foot,  1 07 1 

tendon  suture,  1076 

Wall  chest  tumors,  267 
Walsham,  club-foot,  1109 

dislocation  peroneus  tendon,  1080 
Wachsmann,  Freund's  operation,  265 
Wardrop's  operation,  706 
Ware,  exposure  pericard,  273 
Warren,  osteomyelitis,  814 

excision  breast,  245 
Wassiljew,  vasectomy,  580 
Watson's  drainage  tube,  583 

nephrostomy,  534,  577 
Wax  Horseley's,  7 
Webbed  fingers,  1009 
Weber's  incision,  83 
Weglowski,  anchylosis  elbow,  999 
Weinhold,  dislocation  shoulder,  970 
Weir,  appendicostomy,  363 

bunion,  948 

excision  rectum,  409 

incision  appendicitis,  373 

trigger  finger,  loii 
Wens,  I 

Wenzel  von,  varicose  veins,  748 
Werndorff,  osteotomy  knee,  924 
West,  hypophysectomy,  51 
Wetherill's  drain,  655 

operations,  piles,  419 
White,  J.  W.,  castration,  580 

epilepsy,  44 

interscapsulo-thoracic  amputation 

1045 

vasectomy,  619 
White,  Sinclair,  excision  jaw,  91 
Whitehead,  excision  tongue,  141 

mouth  gag,  136 

operation,  418 
Whitehouse,  angioma,  4 
Whiting,  mastoid  operation,  34 
Whitman,  osteotomy,  839 

hip,  875 

tendon  transplantation,  1091 
Wieting  Pasha  artery  vein  anastomosis, 

702 
Willem's  excision  rectum,  392 
Wi,let,  tendon  shortening,  1092 
Wilms,  ureterostomy,  534 
Winslow,  foramen,  hernia,  507 
Wire  mesh,  implantation  hernia,  505 

sutures,  687 
Wiring  bones,  770 

olecranon,  806 

patella,  793 
Witzel,  excision  rectum,  392 

gastrostomy,  293 


INDEX. 


II53 


Witzel,  uretero-cystostomy,  554 
Wohlgemuth,  pancreatic  fistulas,  434 
Wohlgemuth,  trauma  pancreas,  439 
Wolff,  tendon  suture  to  periosteum, 

1078 
Wolfler,  gastro-enterostomy,  300 
Wolf's  grafts,  683 
Wood's  operation  ectopia  vesicae,  557 

hypospadias,  604 
Woolsey,  pancreatitis,  433 
Wounds,  arteries,  692 

bladder,  566 

cavernous  sinus,  70 

diaphragm,  510 

of  dura,  13 

hand,  1015 

intestine,  331 

of  joints,  1022 

knee,  905 

longitudinal  sinus,  16 

lung  and  pleura,  246 

oesophagus,  193 

pericard,  273 

renal  pelvis,  suture,  535 

scalp  closure,  12 

spine,  640 

stomach,  290 

tendons,  1077 

of  veins,  737 


Wound,  vena  cava,  737,  541 
Wreden's  operation  knee,  932 
Wrench,  Thomas',  11 04 
Wrist  anchylosis,  1006 

joint,  1002 
Wry  neck,  1 74 
Wullstein,  dislocation  patella,  934 

ventral  hernia,  506 
Wyeth,  colostomy,  362 

pins,  1060,  1061 
Wyeth's  amputation,  1064 
Wynter,  ascites,  425,  427 

X-ray,  exophthalmic  goitre,  220 
gangrene  lung,  269 

Young,  cancer  prostate,  587 

cystectomy,  575 

prostatectomy,  579 

tractor,  584 

ureteral  stone,  551 

vasectomy,  etc.,  620 
Young,  J.  K.,  bunion,  947 

Zuckerkandl's     incision     nephrotomy, 

515 
prostatectomy,  585 
Zoudek,  nephrotomy,  533 


73 


